What are central lesions in bronchoscopy?

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Central Lesions in Bronchoscopy: Definition and Clinical Significance

Central lesions in bronchoscopy refer to abnormalities located in the trachea, main bronchi, or segmental bronchi that are directly visible during bronchoscopic examination. These lesions are distinct from peripheral lesions, which are located beyond the segmental bronchi and not directly visible with standard bronchoscopy 1.

Anatomical Definition and Classification

Central airway lesions are characterized by their location in the:

  • Trachea
  • Main (primary) bronchi
  • Lobar (secondary) bronchi
  • Segmental (tertiary) bronchi

These lesions can be categorized as:

  1. Exophytic endobronchial masses - Tumors growing into the airway lumen
  2. Submucosal spread - Lesions growing beneath the mucosa
  3. Peribronchial tumors - Causing extrinsic compression of airways 1

Diagnostic Characteristics

Visibility and Diagnostic Yield

  • Central lesions are directly visible during standard white light bronchoscopy (WLB)
  • Diagnostic yield is significantly higher for central lesions (88% overall sensitivity) compared to peripheral lesions (78%) 1
  • Direct forceps biopsy of visible central lesions has a sensitivity of 74% 1

Sampling Techniques for Central Lesions

For optimal diagnosis of central lesions, multiple sampling techniques are recommended:

  • At least three forceps biopsies of visible lesions
  • Bronchial washings (48% sensitivity)
  • Bronchial brushings (59% sensitivity)
  • Endobronchial needle aspiration for submucosal or peribronchial lesions 1

Clinical Significance and Presentations

Central airway lesions may present with:

  • Persistent cough (often unresponsive to standard therapy)
  • Hemoptysis
  • Dyspnea (especially with significant airway obstruction)
  • Wheezing (often monophonic)
  • Stridor (with severe narrowing)
  • Postobstructive pneumonia 1

Central Airway Obstruction

When central lesions cause significant narrowing, this is termed Central Airway Obstruction (CAO), which can be:

  • Malignant (primary lung cancer or metastatic disease)
  • Non-malignant (granulomatous disease, tracheobronchomalacia, etc.) 2

Types of Central Lesions

1. Malignant Lesions

  • Primary lung cancers (especially squamous cell carcinoma)
  • Metastatic tumors to the airway
  • Carcinoma in situ and preinvasive lesions 1

2. Benign Tumors

  • Hamartomas
  • Papillomas
  • Granular cell tumors

3. Inflammatory/Infectious Lesions

  • Tuberculosis granulomas (29% of multinodular lesions)
  • Fungal infections
  • Tracheobronchopathia osteochondroplastica 3

4. Structural Abnormalities

  • Tracheobronchomalacia
  • Tracheal stenosis
  • Extrinsic compression 1

Advanced Diagnostic Approaches

Autofluorescence Bronchoscopy (AFB)

  • Enhances detection of small preinvasive lesions not visible with standard WLB
  • Particularly useful for detecting carcinoma in situ and severe dysplasia 1

Radial Probe Endobronchial Ultrasound (RP-EBUS)

  • Assesses invasion depth of central lesions in the tracheobronchial wall
  • Guides treatment planning with 90% accuracy in determining tumor invasion depth 4

Management Considerations

Central lesions may require various interventional bronchoscopic techniques:

  • Mechanical debridement
  • Laser therapy
  • Electrocautery
  • Cryotherapy
  • Photodynamic therapy
  • Brachytherapy
  • Airway stent placement 5

Clinical Pitfalls and Caveats

  1. Missed Diagnoses: Some central lesions may not be visible on chest radiographs but are evident on CT or bronchoscopy. In smokers with persistent cough or hemoptysis, bronchoscopy is indicated even with normal chest radiographs 1.

  2. Sampling Errors: Submucosal lesions may be missed with standard forceps biopsies. Endobronchial needle aspiration should be considered for these cases 1.

  3. Pediatric Considerations: In children, central airway lesions may present differently, with stridor being a common symptom. Both upper and lower airways should be examined during bronchoscopy in pediatric cases 1.

  4. Treatment Planning: The depth of invasion of central lesions is critical for planning interventional procedures. RP-EBUS should be considered before interventional treatments to avoid complications 4.

Central lesions in bronchoscopy represent a diverse group of pathologies that require careful evaluation and often multiple sampling techniques for accurate diagnosis. Their central location makes them more accessible to direct visualization and intervention compared to peripheral lesions.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Interventional Therapies for Central Airways.

Journal of thoracic imaging, 2019

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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