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Ann Thorac Med. 2012 Jan-Mar; 7(1): 21–25.
PMCID: PMC3277036

Descriptive data on cancerous lung lesions detected by auto-fluorescence bronchoscope: A five-year study



Auto-fluorescence bronchoscopy (AFB) has been used for the identification and localization of intra-epithelial pre-neoplastic and neoplastic lesions within the bronchus.


To determine the applicability of AFB for the detection and localization of precancerous and cancerous lesions, in addition to analyzing the morphologic presentation, their association to histological type and the variation between genders.


A five-year study involving 4983 patients, who underwent routine bronchoscopy [B] examination in a local tertiary teaching hospital, was done. The B examination was performed under intratracheal lidocaine, and samples were obtained using suitable approach. One thousand four hundred and eighty-five pathologically confirmed lung cancer patients were included in the study. The following parameters were studied: Morphological presentation, biopsy sites, histology. Differences between the groups were analyzed using Chi square test.


One thousand four hundred and eighty-five patients who had hyperplasia or neoplastic lesions were further confirmed as lung cancer pathologically. Lung cancer was more commonly found in the right lung (51.58% vs. 42.82%). The lesion occurred more frequently in the upper lobe than the lower lobe (44.17% vs. 22.42%). Male patients with squamous cell carcinoma showed upper lobe involvement more commonly, while the left main bronchus was more commonly involved in female patients. Adenocarcinoma mostly involved lesion of the upper lobe. Squamous cell carcinoma and small cell carcinoma were the major proliferative types (80.15% and 76.16% respectively).


AFB is efficient in the detection of pre-invasive and invasive lung lesions. The morphological presentation is associated to the histological type. There is variation in the presentation and histology of cancerous lung lesions between genders.

Keywords: Auto-fluorescence bronchoscopy, gender, invasive lesion, lung cancer, screening

Lung cancer is a leading cause of cancer deaths in the world. The worsening of the risk factors for the disease and the aging of the population may be the two major contributors to the current status, that lung cancer has become one of the most common malignant neoplasms in China.[1,2] The majority of patients are already in a fairly advanced stage when they first seek medical attention and only 25-30% of patients can be offered therapeutic resection at most.[3] Characteristically, lung cancer arising from the bronchial mucosa (central type lung cancer) at its initial development is radiological occult. The intra-epithelial neoplastic lesions may be asymptomatic and can only be identified by bronchoscopy using light in the blue spectral region. Screening test using sputum cytology has been used with limited success.[4] Evaluation of low-dose spiral computer tomography (CT) scan as a screening tool for lung cancer is being studied,[5] and its limitations include high costs, need for repeated scanning and necessity to obtain histological confirmation with additional procedures. Bronchoscope techniques appear to be a promising tool in the early diagnosis of lung cancer in high-risk patient groups,[6] as they allow visualization of early morphological changes in the lung and taking samples for pathological confirmation.

Fluorescence bronchoscope for localization of early neoplastic changes in the bronchial mucosa was clinically introduced in the early 1980s; the method was based on the principle associated with drug-induced fluorescence using light emission from a hemotoporphyrin derivative. Autofluorescence diagnosis relies on the emission from endogenous fluorophores, following light absorption, to provide contrast between normal and abnormal tissue. Auto-fluorescence bronchoscopy (AFB) has reportedly increased the identification and localization of early neoplastic lesions of the bronchial mucosa.[6] The established applications of AFB include sputum examination; examination of patients with prolonged cough and hemoptysis; follow-up for airway recurrence after surgery; and monitoring the therapeutic effect on tracheal tumors.

The aim of this study was to determine the applicability of AFB for the detection and localization of precancerous and cancerous lesions, in addition to analyzing the morphologic presentation, their association to histological type and the variation between genders.


Four thousand nine hundred and eighty-three patients underwent routine bronchoscopy examination during 2004 to 2009 at our department. Olympus BF-XP 260 F bronchofiber videoscope was used for the examination and EVIS LUCERA BF-260 broncho videoscope system was used. The examination was performed under local anesthesia with three subsequent sprays of 7% lidocaine each at five-minute intervals, followed by intratracheal injection of 5% lidocaine; the samples were obtained using suitable approach of forceps’ biopsy, transbronchial needle aspiration and bronchial brushing with aspiration. One thousand four hundred and eighty-five patients were pathologically confirmed as lung cancer. All the pathologically confirmed cases of lung cancer were included in the study. The following parameters were studied: Morphologic presentation, biopsy sites, and histology. The case records of patients were observed for age, sex, smoking status, blood-gas, X-ray/CT, Complete Bold Count, Electro cardiogram, Prothrombin Time, and Activated Partial Thromboplastin Time.

Statistical analysis

Descriptive data were recorded for all parameters. The clinical variables including pathological and bronchoscope reporting were processed using SPSS 13.0 statistical software, and χ2 test was done for relative frequency representation. A P<0.05 was considered statistically significant.


Gender distribution

Among the total patients who underwent B, 3314 were male and 1669 were female. The male to female ratio for pathologically confirmed lung cancer cases was 1148:337. The incidence among male patients was significantly higher (χ2 =110.775, = 110.775, P<0.001). The results showed 680 patients with squamous cell carcinoma (45.79%), 371 with adenocarcinoma (24.98%), 432 with small cell carcinoma (29.09%), and two with adenosquamous carcinoma (0.14%). The detection rate for squamous cell carcinoma in males (54.61%) was significantly higher than that in females (15.73%), (χ2 =158.732; = 158.732; P<0.001). The incidence of adenocarcinoma and small cell carcinoma was higher in females (49.85% and 34.42%) than in males (13.67% and 21.28%) (χ2 = 6.005, P=0.014) [Table 1].

Table 1
Pathological type of cancer and variation between the genders

Age distribution

Pathologically confirmed cancer was highest among patients above 40 years of age. Squamous cell carcinoma and adenocarcinoma had a higher prevalence among patients older than 60 years. The male to female ratio for squamous cell carcinoma was 55.5%:58.49%; and 54.19%:46.43% for adenocarcinoma. Small cell carcinoma was more common in patients between 40 to 59 years of age (male:female ratio was 50.62%:49.14%) [Table 2].

Table 2
Pathological cancer types in subjects and distribution between age groups

Location of lesion

The right lung showed a higher involvement (579 males and 187 females) than the left lung (502 males and 134 females). The upper lobe was the more frequent site of lesion (522 males, 134 females) than the lower lobe (250 males, 83 females). The right upper lobe lesion (21.52%) was more common than the left upper lobe lesion (20.57%); 22.5% of female patients showed involvement of the right upper branch. Male patients with squamous cell carcinoma showed upper lobe involvement, while the left main bronchus was most commonly involved in female patients. Adenocarcinoma mostly involved lesions of the upper lobe. The right and left upper lobes were frequently involved in male patients diagnosed with small cell lung cancer, whereas female patients mostly presented with right upper, middle and left upper lobe lesions for small cell cancer. Involvement of the trachea and carina was seen in 15 patients, of which nine cases were of squamous cell carcinoma. Mixed tumor types were seen in 68 patients and involved bilateral lung fields [Table 3].

Table 3
Morphological location, gender variation and pathological lung cancer type

Morphologic presentation and microscopic view

One thousand and twenty-two cases of hyperplasia (68.82%) were noted, and these had multiple patterns (mainly nodular, cauliflower-like, polyploidy, and irregular); 389 cases of invasive lesion (26.2%) showed mucosal roughening, congestion, edema, erosion, necrosis, and purulent secretion under the microscope. Fifty cases of compression (3.37%) and 24 cases with normal presentation (1.62%) were observed. Squamous cell carcinoma and small cell carcinoma were the major proliferative types (80.15% and 76.16% respectively) [Table 4 and Figure 1].

Table 4
Morphological presentation and pathological lung cancer type
Figure 1
AFB view of lung lesions. (a) Superior view of a normal tracheal bifurcation; (b) Mild inflammation of the right main bronchus; (c) Mild inflammation of the left main bronchus; (d) Hyperemia at the right upper bronchus; (e) Exudation from the left lower ...


Less than 15% of all patients survive five years after a diagnosis of lung cancer.[6] In the absence of a reliable screening program less than 15% of patients are diagnosed with an early Stage I cancer. In China and across the globe, 80% of patients are ineligible for surgical resection at diagnosis, mostly because of the advanced stage of cancer and also due to poor general condition. Among the methods used for the diagnosis of lung cancer, bronchoscopy serves as an important tool involved with diagnosis, staging, and management of lung cancer.[7] Technological advancements have allowed for the emergence of newer modalities to evaluate endobronchial, parenchyma, and mediastinal pathology.[8] Conventional techniques such as white light video bronchoscopy and its ancillary procedures (forceps biopsy, brush biopsy, bronchoalveolar lavage, bronchial washings, and transbronchial needle aspiration) help with accuracy in relation to tumor location, size, and type. This study aimed to evaluate the contribution of AFB in the diagnosis of lung cancer, on a hospital site, over a period of five years.

The results of our study show that out of 4983 patients, 3314 cases involved male patients, which represents that male subjects more frequently present with lesions apprehensive of lung cancer. This is supported by pathologically confirmed lung cancer in 1148 male subjects, which is in agreement with earlier findings.[911] Our results substantiate a 3.41 times higher possibility of lung cancer in male subjects taking AFB examination. Moreover, the incidence of squamous cell carcinoma was 54.61% in male and 15.73% in females; a possible explanation to this tendency can be the higher prevalence of smoking among male subjects in China[1017] [Table 1].

Transbronchial needle aspiration (TBNA) is a minimally invasive and increasingly utilized technique to diagnose and stage lung cancer. Large case series[8,18] have reported a diagnostic accuracy of 70-95%, depending upon several factors including operator and cytopathology expertise. In the 1485 diagnosed cases of lung cancer we noted squamous cell carcinoma (45.79%), small cell carcinoma (29.09%), adenocarcinoma (24.98%), and adenosquamous carcinoma (0.14%). These findings advocate that suspicious peripheral and central airway lesions investigated with AFB have a higher chance for pathological confirmation. Hence, AFB examination should be the initial investigation once clinical features are suggestive of a mass bronchial lesion in the chest.[19] The female cases had a higher incidence of adenocarcinoma (49.85%) and small cell carcinoma (34.42%), which is in agreement with earlier findings related to the occurrence of lung cancer type in female subjects.[11,20,21] We also observed a yearly increase in the incidence of squamous cell carcinoma among female subjects, perhaps increasingly popular smoking behavior is an explanation[22,23] [Table 2].

The results show a positive relation between lung cancer incidence and old age. The high incidence of lung cancer among elderly subjects may be related to factors like smoking status, food habits, occupational exposure and infectious diseases.[20,21,2426] Moreover, the lack of observed gender predisposition for lung cancer types among subjects more than 50 years of age supplements ours assumption that the elderly in China are predisposed to malignancy.[27] Bronchial carcinomas typically involve the main, middle and segmental bronchus. Our results show a higher incidence in the right lung and frequent involvement of the upper lobe. These findings are possibly related to the variation in vascular, lymphatic and anatomic structures. An earlier study[6] has shown a correlation between morphological abnormality and pathological types. This study found morphological patterns relative to cancer types and provided clues before the pathological confirmation was made. Our study found that adenocarcinoma presents as an invasive pattern; while squamous cell carcinoma and small cell carcinoma have a proliferative presentation under AFB [Tables [Tables33 and and44].

Our study has certain limitations; first there is no arm of conservative follow-up. Secondly, it is a single-center study and involves a group of physicians with a similar approach. We believe that a multi-centric study will provide a better approach in the generalization of results.

In conclusion, AFB is efficient in the detection of pre-invasive and invasive bronchial cancer lesions. Our study proposes that AFB may be used in the screening of lung cancer. Though newer technologies, such as narrow band imaging, endoscopic ultrasound, endobronchial ultrasound, electromagnetic navigation, optical coherence tomography, and con-focal fluorescent laser microscopy are favorite clinical investigations in the developed world, they are yet to prove their medico-economic viability in the developing world.


The authors would like to express their gratitude to the medical staff at the Department of Pathology, the Department of Respiratory Medicine and the Medical Record Section for their help in obtaining the data.


Source of Support: Nil,

Conflict of Interest: None declared.


1. Yang L, Li L, Chen Y, Parkin DM. Mortality time trends and the incidence and mortality estimation and projection for lung cancer in China. Zhongguo Fei Ai Za Zhi. 2005;8:274–8. [PubMed]
2. Li Z, Yu Y, Lu J, Luo Q, Wu C, Liao M, et al. Analysis of the T descriptors and other prognosis factors in pathologic stage I non-small cell lung cancer in China. J Thorac Oncol. 2009;4:702–9. [PubMed]
3. Huang GJ, Mao YS, Zhang DC, Sun KL, He J, Cheng GY. Current status and future directions of surgery for lung cancer in China. Chin Med J (Engl) 2007;120:619–21. [PubMed]
4. Fan YG, Hu P, Jiang Y, Chang RS, Yao SX, Wang W, et al. Association between sputum atypia and lung cancer risk in an occupational cohort in Yunnan, China. Chest. 2009;135:778–85. [PubMed]
5. Jiang T, Zheng X, Tao X, Liu H, Liu S. How to choose PET-CT or CT in the diagnosis and staging of lung cancer. Practical experience in China. Nuklearmedizin. 2010;49:28–34. [PubMed]
6. 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. [PubMed]
7. El-Bayoumi E, Silvestri GA. Bronchoscopy for the diagnosis and staging of lung cancer. Semin Respir Crit Care Med. 2008;29:261–70. [PubMed]
8. Iwano S, Imaizumi K, Okada T, Hasegawa Y, Naganawa S. Virtual bronchoscopy-guided transbronchial biopsy for aiding the diagnosis of peripheral lung cancer. Eur J Radiol. 2011;79:155–9. [PubMed]
9. Zeng Y, Liang J, Shen H. The characteristics of lung cancer cases in 1996-2005 in Nanjing, China. Zhongguo Fei Ai Za Zhi. 2008;11:406–9. [PubMed]
10. Gan Q, Smith KR, Hammond SK, Hu TW. Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China. Tob Control. 2007;16:417–22. [PMC free article] [PubMed]
11. Zou XN, Jiang JM, Liu BQ, Zeng XJ, Wu YP, Chen YL, et al. Study on the relations between smoking and the risk of age-specific lung cancer deaths in urban and rural areas of China. Zhonghua Liu Xing Bing Xue Za Zhi. 2009;30:907–10. [PubMed]
12. Lin HH, Murray M, Cohen T, Colijn C, Ezzati M. Effects of smoking and solid-fuel use on COPD, lung cancer, and tuberculosis in China: A time-based, multiple risk factor, modelling study. Lancet. 2008;372:1473–83. [PMC free article] [PubMed]
13. Jiang J, Liu B, Nasca PC, Chen J, Zeng X, Wu Y, et al. Age-related effects of smoking on lung cancer mortality: A nationwide case-control comparison in 103 population centers in China. Ann Epidemiol. 2008;18:484–91. [PubMed]
14. Hu J, Galeone C, Lui R, Pelucchi C, La Vecchia C, Negri E. Smoking and lung cancer in Harbin, northeast China. Ann Oncol. 2005;16:1605–8. [PubMed]
15. Xin Y, Qian J, Xu L, Tang S, Gao J, Critchley JA. The impact of smoking and quitting on household expenditure patterns and medical care costs in China. Tob Control. 2009;18:150–5. [PMC free article] [PubMed]
16. Ding D, Hovell MF, Ji M, Hofstetter CR, Zheng P, Fu H, et al. Employment and social “determinants” of smoking in urbanizing China: A representative survey. Nicotine Tob Res. 2009;11:779–84. [PMC free article] [PubMed]
17. Yan J, Xiao S, Ouyang D, Jiang D, He C, Yi S. Smoking behavior, knowledge, attitudes and practice among health care providers in Changsha city, China. Nicotine Tob Res. 2008;10:737–44. [PubMed]
18. Kawaraya M, Gemba K, Ueoka H, Nishii K, Kiura K, Kodani T, et al. Evaluation of various cytological examinations by bronchoscopy in the diagnosis of peripheral lung cancer. Br J Cancer. 2003;89:1885–8. [PMC free article] [PubMed]
19. Yung RC. Tissue diagnosis of suspected lung cancer: Selecting between bronchoscopy, transthoracic needle aspiration, and resectional biopsy. Respir Care Clin N Am. 2003;9:51–76. [PubMed]
20. Liang H, Guan P, Yin Z, Li X, He Q, Zhou B. Risk of lung cancer following nonmalignant respiratory conditions among nonsmoking women living in Shenyang, Northeast China. J Womens Health (Larchmt) 2009;18:1989–95. [PubMed]
21. Pronk A, Coble J, Ji BT, Shu XO, Rothman N, Yang G, et al. Occupational risk of lung cancer among lifetime non-smoking women in Shanghai, China. Occup Environ Med. 2009;66:672–8. [PMC free article] [PubMed]
22. Finch K, Ma S, Qin D, Xin G, Xia W, Novotny TE. Smoking knowledge, attitudes and behaviors among rural-to-Urban migrant women in beijing, China. Asia Pac J Public Health. 2010;22:342–53. [PMC free article] [PubMed]
23. Xiao L, Yang J, Wan X, Yang GH. What is the prevalence of smoking in China. Zhonghua Liu Xing Bing Xue Za Zhi. 2009;30:30–3. [PubMed]
24. Yang L, Yang G, Zhou M, Smith M, Ge H, Boreham J, et al. Body mass index and mortality from lung cancer in smokers and nonsmokers: A nationally representative prospective study of 220,000 men in China. Int J Cancer. 2009;125:2136–43. [PubMed]
25. Wang Y, Wang A, Jiang R, Pan H, Huang B, Lu Y, et al. Human papillomavirus type 16 and 18 infection is associated with lung cancer patients from the central part of China. Oncol Rep. 2008;20:333–9. [PubMed]
26. Galeone C, Pelucchi C, La Vecchia C, Negri E, Bosetti C, Hu J. Indoor air pollution from solid fuel use, chronic lung diseases and lung cancer in Harbin, Northeast China. Eur J Cancer Prev. 2008;17:473–8. [PubMed]
27. Bonner MR, Shen M, Liu CS, Divita M, He X, Lan Q. Mitochondrial DNA content and lung cancer risk in Xuan Wei, China. Lung Cancer. 2009;63:331–4. [PMC free article] [PubMed]

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