ORIGINAL ARTICLE |
https://doi.org/10.4103/ijrc.ijrc_92_22 |
Lung Cancer Diagnosis by Bronchoscopy at Tertiary Care Center: A Retrospective Analysis
Department of Respiratory Medicine, Dr. M. K. Shah Medical College and Research Centre, 1Department of Respiratory Medicine, G. C. S. Medical College, Hospital and Research Centre, 2Department of Respiratory Medicine, B. J. Medical College, Ahmedabad, Gujarat, India
E-mail: kur.mbbs276@gmail.com
Abstract
Introduction: Lung cancer stands second ranked among all cancers with an incidence of 11.4% worldwide. In India, it remains the fourth-most common cancer with an incidence of 5.5% and mortality of 7.8%. The surveillance, epidemiology, and end results (SEER) database is used by the American Cancer Society to access survival rates for various cancer types. Five-year survival of nonsmall-cell lung cancer and small-cell lung cancer by SEER stages is ranging from 8% to 64% and 3% to 29%, respectively, majorly influence by the spread of cancer. Objectives: To study the demography of lung cancer and establish the utility of bronchoscopy in lung cancer diagnosis. Materials and Methods: A retrospective observational study was carried out on patients having radiologically proven lung mass in the period of November 2017 to October 2020. Results: A total of 416 patients, had a mean (standard deviation [SD]) age of 58.1 (10.1) years, including 83.7% males. Most were smokers (79.8%) with a mean (SD) smoking index of 506.45 (252.16). The most common types of lung cancer in descending order were adenocarcinoma (ADC) (43.8%), squamous cell carcinoma (34.9), small-cell lung cancer (12%), and others (9.3%). Upper lobe involvement (46.8%) was more common. At the time of diagnosis, 72.6% of total patients were presented with a stage III or higher index of severity. The yield of endobronchial biopsy, bronchoalveolar lavage, transbronchial lung biopsy, transbronchial needle aspiration, and brushing were 87.8%, 45.5%, 64.1%, 53.2%, and 45.1%, respectively, with overall diagnostic yields of 69.9%. Conclusion: Lung cancer is mainly discovered in the elderly, males, and smokers with advanced pathological stages. The most common morphology of lung cancer is ADC. Bronchoscopy is considered an initial tool for the assessment of lung mass and shows a higher diagnostic yield in centrally located tumors.
Keywords: Biopsy, bronchoscopy, lung cancer, morphology
How to cite this article: Patel KM, Chauhan BA, Shah NT. Lung cancer diagnosis by bronchoscopy at tertiary care center: A retrospective analysis. Indian J Respir Care 2022;11:358-62.
Received: 29-04-2022
Revised: 05-08-2022
Accepted: 07-08-2022
Published: 12-11-2022
INTRODUCTION
It estimates that 1 in 5 people will develop cancer during their whole lives (1 in 8 males and 1 in 11 females).[1] According to Globocon 2020, the second-most common cancer is lung cancer with an incidence of 11.4% affecting 2.2 million. It carries the highest mortality number of 1.8 million (18%). The incidence is 14.3% in males (1.4 million) and 8.4% (770,000) in females.[2] In India, the incidence of lung cancer is 7.8% in males (51765) and 3.1% in females (20835). It remains the fourth-most common cancer in India with an incidence of 5.5% (72510) and mortality of 7.8% (66279).[3] As per the National Cancer Registry Programme India, lung cancer incidence is expected in males 71,788 (1 in 68) and in females 26490 (1 in 201) with a cumulation of 98278 (1 in 101).[4]
The morphology pattern of lung cancer appears to be changing, with adenocarcinoma (ADC) being equal or even higher than squamous cell carcinoma (SqCC) in terms of the probability of occurrence in some Asian and most Western countries.[5,6] However, the pathological and clinical profile of lung cancer in India appears to show large variations. In addition, longer trends in lung cancer demographics are sparsely studied, and most centers report their results within short periods.[7]
MATERIALS AND METHODS
It was a retrospective observational analysis that involved consecutive 416 patients with radiologically diagnosed lung mass in duration from November 2017 to October 2020 in the Respiratory Medicine department at a tertiary care center. The ethical approval was obtained from the institutional ethical committee.
Clinical details were recorded in a decided formulated pattern that includes demographic details such as age, sex, a detailed smoking history (current smoker and nonsmoker in form of cigarette, bidi, and hookah), previous treatment history, and imaging details. Radiological evidence suggested mass lesions in the lung were included in the study. Multiple varieties of diagnostic modalities were utilized: (1) Bronchoscopy guided-end bronchial biopsy, transbronchial lung biopsy (TBLB), transbronchial needle aspiration (TBNA), bronchoalveolar lavage (BAL), and Brushing and (2) without the guidance of bronchoscope-computerized tomography (CT)-guided biopsy, ultrasonography (USG)-guided biopsy and tru-cut biopsy.
Figure 1 shows a flow chart of participants for inclusion in the present study. Patients had a history of isolated pleural effusion, hemodynamic instability, uncooperative, refused consent for the procedure, and radiological imagine inconclusive of mass were excluded from the study.
The morphological analysis was performed according to WHO grading of lung cancer (1) Nonsmall-cell lung cancer-ADC, SqCC, Non Small Cell Lung Carcinoma - Not Otherwise Specified (NSCLC-NOS), (2) small-cell lung carcinoma (SCLC), (3) Others.[8]
Staging of cancer was carried out by CT scan chest and upper abdomen, CT scan head and neck, Brain CT or whole-body positron emission tomogram CT, magnetic resonance imaging brain or bone scanning. The staging was based on the system of the 8th edition of the International Association for Study of Lung Cancer.[9] SCLC classification of two stages: limited vs. extensive, was analyzed as per American Joint Commission for Cancer TNM system.[10]
Statistical analysis
Data were collected in prepared pro forma and arranged in excel file. The variables quantitative in nature were expressed in mean ± standard deviation (SD). The categorical variables were shown as frequency and percentage. The correlation between the two defined variables was judged by a t-test or Chi-square test. The data analysis was performed using IBM SPSS (Statistical Package for the Social Sciences) 20.0 (IBM, Chicago city, Illinois, USA) software. P < 0.05 was considered to be statistically significant, marked as bold letter in table.
Figure 1: Flow chart of patients screening and inclusion in the study
RESULTS
The demographic baseline characteristics of malignant lung disease are shown in Table 1. The mean (SD) age was 58.15 (10.16). The proportion of male patients was higher (83.7%) compared to females (16.3%). There were 332 (79.8%) smokers and 84 (20.2%) nonsmokers. The mean (SD) smoking index was 506.45 (252.16) with a higher percentage of heavy smokers. The right-sided and upper lobe pathology was more common. ADC (43.8%) was the most common pathology detected in lung cancer patients, followed by SqCC (34.9%), small-cell carcinoma (SCLC) (12%), and others (5.5%). The pre-malignant lesion was depicted in 3.8% of cases. According to Stage NSCLC-TNM Staging eighth Ed, there were a higher percentage of stage three and stage four patients, 42.8% and 29.8%, respectively. Advanced SCLC was detected in 58% of individuals.
| Variables (n=416) | Subgroups | n (%) |
| Age (years) | Mean±SD | 58.15±10.16 |
| Sex | Male | 348 (83.7) |
| Female | 68 (16.3) | |
| Smoking status | Smokers | 332 (79.8) |
| Nonsmokers | 84 (20.2) | |
| Smoking | Mean±SD | 506.45±252.16 |
| index (n=332) | <100 | 23 (6.9) |
| 100-300 | 69 (20.8) | |
| 301-600 | 112 (33.7) | |
| >600 | 128 (38.6) | |
| Laterality (n=416) | Right | 227 (54.6) |
| Left | 170 (40.9) | |
| Bilateral | 17 (4.1) | |
| Undefined | 2 (0.4) | |
| Predominant lobe | Upper | 195 (46.8) |
| involvement (n=416) | Middle/lingular | 45 (10.8) |
| Lower | 88 (21.2) | |
| Others | 88 (21.2) | |
| Morphology | ADC | 182 (43.8) |
| SqCC | 145 (34.9) | |
| SCLC | 50 (12) | |
| NSCLC - NOS | 23 (5.5) | |
| Premalignant | 16 (3.8) | |
| Stage NSCLC - TNM | Tis N0 M0 | 4 (1.1) |
| staging 8th ed.. | Tx N0 M0 | 12 (3.3) |
| ition (n=366) | I | 27 (7.4) |
| II | 57 (15.6) | |
| III | 157 (42.8) | |
| IV | 109 (29.8) | |
| Small cell | Limited stage | 21 (42) |
| carcinoma (n=50) | Extensive stage | 29 (58) |
SD: Standard deviation, ADC: Adenocarcinoma, SCLC: Small cell lung cancer, NSCLC: Non-SCLC, NOS: Not otherwise specified, TNM: Tumor, node, metastasis, SqCC: Squamous cell carcinoma
Table 2 shows lung cancer cases comparison among smokers and nonsmoker groups. This firmly suggests that smokers developed lung cancer at an earlier age than nonsmokers. Smoking rates were higher in men than in women (95.9% vs. 4.1%). Overall, the incidence of ADC was higher in both groups, but SqCC, SCLC, and NSCLC (NOS) were commonly observed in smokers.
A comparison of lung cancer morphology is shown in Table 3. It defines that parameters such as age, sex, smoking status, smoking index, and stage of severity were evenly distributed in all groups of patients. The incidence among males was significantly higher compared to females. It was observed that in ADC, SqCC, and SCLC, upper lobe involvement was almost two times more common than lower lobe involvement. NSCLC-NOS were more likely to exhibit lower lobe pathology. However, more research is required to emphasize lobular dominance in each type of lung cancer.
The various methods utilized to diagnose lung cancer are shown in Table 4. Each morphology of lung cancer diagnosed by bronchoscopy has been demonstrated which has not previously been studied in detail. Out of the total of 660 biopsies, there were 447 biopsies had positive malignancy results (72.3%). Visible endobronchial lesions were observed more among SqCC (56%) and SCLC (61.7%) groups compared to ADC (35.2%) due to the tendency of ADC lesions at peripheral sites. The yield of another bronchoscopic sampling such as TBLB, BAL, TBNA, and brushing detected 64.1%, 45.5%, 53.2%, and 45.1%, respectively. Overall diagnostic yield of lung cancer by bronchoscopic methods was 69.9%. The bronchoscopic procedures yield in SqCC and SCLC were 90.8% and 85%, respectively, due to its tendency to involve central structures of the mediastinum. Other types of lung tissue sampling like tru-cut biopsy, USG-guided biopsy, and CT-guided biopsy had diagnostic values of 85.7% with a higher proportion of ADC (61.9%).
| Variables (n=400) | Subgroups | Smokers (n=320), n (%) | Nonsmokers (n=80), n (%) | P |
|---|---|---|---|---|
| Age (years) | Mean±SD | 55.0±12.39 | 58.9±9.35 | <0.05 |
| Sex | Male | 307 (95.9) | 30 (37.5) | <0.05 |
| Female | 13 (4.1) | 50 (62.5) | ||
| Laterality | Right | 175 (54.7) | 44 (55) | 0.75 |
| (n=416) | Left | 130 (40.6) | 32 (40) | |
| Bilateral | 14 (4.4) | 3 (3.8) | ||
| undefined | 1 (0.3) | 1 (1.2) | ||
| Predominant | Upper | 165 (51.6) | 23 (28.8) | <0.05 |
| lobe | Middle/lingular | 34 (10.6) | 10 (12.4) | |
| involvement (n=416) | Lower | 61 (19.1) | 23 (28.8) | |
| Others | 60 (18.7) | 24 (30) | ||
| Morphology | ADC | 137 (42.8) | 45 (56.3) | 0.06 |
| SqCC | 121 (37.8) | 24 (30) | ||
| SCLC | 45 (14.1) | 5 (6.2) | ||
| NSCLC - NOS | 17 (5.3) | 6 (7.5) | ||
| Stage | I | 24 (7.5) | 3 (3.8) | 0.23 |
| NSCLC-TNM | II | 44 (13.8) | 13 (16.2) | 0.56 |
| staging 8th ed.. ition (n=350) | III | 129 (40.3) | 28 (35) | 0.38 |
| IV | 78 (24.4) | 31 (38.8) | <0.05 | |
| Small cell | Limited stage | 18 (5.6) | 3 (3.8) | 0.39 |
| carcinoma (n=50) | Extensive stage | 27 (8.4) | 2 (2.4) |
SD: Standard deviation, ADC: Adenocarcinoma, SCLC: Small cell lung cancer, NSCLC: Non-SCLC, NOS: Not otherwise specified, TNM: Tumor, node, metastasis, SqCC: Squamous cell carcinoma
| Variables (n=400) | Subgroups | ADC (n=182), n (%) | SqCC (n=145), n (%) | SCLC (n=50), n (%) | NSCLC - NOS (n=23), n (%) |
|---|---|---|---|---|---|
| Age (years) | Mean±SD | 58.73±10.1 | 58.41±9.74 | 56.46±7.7 | 55.5±13.3 |
| Sex | Male | 139 (76.4) | 131 (90.3) | 48 (96) | 19 (82.6) |
| Female | 43 (23.6) | 14 (9.7) | 2 (4) | 4 (17.4) | |
| Smoking status | Smokers | 137 (75.3) | 121 (83.4) | 45 (90) | 17 (73.9) |
| Nonsmokers | 45 (24.7) | 24 (16.6) | 5 (10) | 6 (26.1) | |
| Smoking index | Mean±SD | 513.2±230.25 | 517.0±263.88 | 467.8±267.8 | 528.0±284.2 |
| Predominant lobe | Upper | 96 (52.7) | 67 (46.2) | 19 (38) | 6 (26.2) |
| Middle/lingular | 17 (9.3) | 20 (13.8) | 6 (12) | 1 (4.3) | |
| Lower | 41 (22.5) | 25 (17.2) | 7 (14) | 11 (47.8) | |
| Others | 28 (15.5) | 33 (22.8) | 18 (36) | 5 (21.7) | |
| Stage | I | 14 (7.6) | 11 (7.6) | NA | 2 (8.6) |
| NSCLC - TNM | II | 31 (17.1) | 21 (14.5) | 5 (21.7) | |
| Staging 8th ed.. ition (n=350) | III | 68 (37.4) | 77 (53.1) | 12 (52.3) | |
| IV | 69 (37.9) | 36 (24.8) | 4 (17.4) | ||
| Small cell | Limited stage | NA | NA | 21 (42) | NA |
| carcinoma (n=50) | Extensive stage | 29 (58) |
SD: Standard deviation, ADC: Adenocarcinoma, SCLC: Small-cell lung cancer, NSCLC: Non-SCLC, NOS: Not otherwise specified, TNM: Tumor, node, metastasis, SqCC: Squamous cell carcinoma, NA: Not available
DISCUSSION
Advancing age is a major risk factor for lung cancer. It is most commonly seen between the ages of 40 and 70, and its prevalence increases with age and reaches the highest value in the sixth to seventh decades.[10] The occurrence of lung cancer is lower in young adults (around 5 to10% under 50 years of age). This group of young adults usually has a positive family history and the most common cancer pathology is ADC.[11] The average age of the present study group was 58.1 years, which is quite similar to other Indian studies.[7,12-16] In addition, the present study also supports a higher frequency of lung cancer in men in comparison to women.[7,12-21]
There was a higher incidence of lung cancer among smokers. As shown in Table 5, the percentage of smokers in various studies of lung cancer is higher, ranging 52%-89% which is comparable with our study (79.8%). The percentage of heavy smokers (smoking index >300) was 69.2% in Mohan et al.[7] which is comparable to our study (72.3%).[15] Similarly, upper lobe predominance pathology was observed in 46.8% of patients in our study who comparable of 51.3% of Mohan et al.[7] Interestingly, smokers had predominantly upper lobe involvement compared to nonsmokers who showed lower lobe predominance which had not clearly defined in previous studies. The various national studies show that the incidence of ADC was higher than SqCC after 2012 [Table 5] which might be explained by rising numbers of lung cancer in younger age group, nonsmokers and female patients.
At the time of initial diagnosis, most NSCLC patients belonged to the advanced stage of the category. Stage III and higher stage of lung cancer were depicted in 72.6% of patients in the present study. In other studies such as Bhattacharya et al.,[22] Furrukh et al.,[23] Mohan et al.,[7] and Singh et al.[15] had noticed 71.8%, 82.1%, 96%, and 97% of patients who had lung cancer pathology of stage III or higher. Similarly, in SCLC, the extensive stage of cancer was more common than the limited stage (Singh et al.[15] vs. Mohan et al.[7] vs. present study: limited stage-44.8% vs. 24.8% vs. 42% and extensive stage-55.2% vs. 75.2% vs. 58% respectively).
Table 6 shows comparisons of various methods for lung cancer detection. The diagnostic outcome is higher in visible endobronchial lesions. Overall, bronchoscopy yield was 69.9% in the present study group, which is comparable to other reference ranges.
| EBB (n=255), n (%) | TBLB (n=145), n (%) | BAL (n=68), n (%) | TBNA (n=32), n (%) | Brushing (n=62), n (%) | Others (n=98), n (%) | All (n=660), n (%) | |
|---|---|---|---|---|---|---|---|
| ADC | 75 (29.4) | 58 (40) | 11 (16.2) | 2 (6.3) | 15 (24.2) | 52 (53.1) | 213 (32.3) |
| SqCC | 97 (38) | 26 (17.9) | 16 (23.5) | 9 (28.1) | 9 (14.5) | 16 (16.3) | 173 (26.2) |
| SCLC | 37 (14.5) | 6 (4.1) | 2 (2.9) | 4 (12.5) | 2 (3.2) | 9 (9.2) | 60 (9.1) |
| NSCLC NOS | 15 (5.9) | 3 (2.1) | 2 (2.9) | 2 (6.3) | 2 (3.2) | 7 (7.1) | 31 (4.7) |
| Malignancy yield | 224 (87.8) | 93 (64.1) | 31 (45.5) | 17 (53.2) | 28 (45.1) | 84 (85.7) | 477 (72.3) |
ADC: Adenocarcinoma, SCLC: Small-cell lung cancer, NSCLC: Non-SCLC, NOS: Not otherwise specified, SqCC: Squamous cell carcinoma, BAL: Broncho alveolar lavage, EBB: Endobronchial biopsy, TBLB: Trans bronchial lung biopsy, TBNA: Trans bronchial needle aspiration
| Author (reference) | Place | Year | Total | Male: female | Mean age (years) | Smokers (%) | ADC (%) | SqCC (%) | ADC : SqCC | SCLC (%) |
| Prasad et al.[12] | Lucknow | 2004 | 400 | 4.3:1 | 57 | 71 | 18.5 | 46.5 | 0.4 | 18.2 |
| Rawat et al.[13] | Uttarakhand | 2009 | 203 | 8.2:1 | 56.4 | 81.77 | 19.38 | 44.83 | 0.43 | 16.75 |
| Sheikh et al.[14] | Kashmir | 2010 | 783 | 6.98:1 | 57.8 | 68.1 | 2.6 | 71.3 | 0.04 | 20.8 |
| Singh et al.[15] | Chandigarh | 2012 | 654 | 5.0:1 | 58.2 | 76.9 | 27.5 | 38.1 | 0.72 | 20.5 |
| Dey et al.[16] | Kolkata | 2012 | 607 | 4.1:1 | 57.9 | 67.2 | 30.8 | 35.1 | 0.88 | 16.5 |
| Noronha et al.[17] | Mumbai | 2012 | 489 | 3.5:1 | 56 | 52 | 43.8 | 26.2 | 1.67 | 8 |
| Krishnamurthy et al.[18] | TamilNadu | 2012 | 258 | 3.5:1 | 56 | 60.5 | 42.6 | 15.8 | 2.7 | 13.2 |
| Malik et al.[19] | New Delhi | 2013 | 434 | 4.6:1 | 55 | 67.9 | 37.1 | 32.1 | 1.16 | 14.7 |
| Murali et al.[20] | Chennai | 2017 | 678 | 3.17:1 | ~ | 53.4 | 51.2 | 16.1 | 3.18 | 9 |
| Kaur et al.[21] | Chandigarh | 2017 | 1301 | 4.6:1 | 58.6 | 76.9 | 36.4 | 36.4 | 1 | 19.2 |
| Mohan et al.[7] | Delhi | 2019 | 1862 | 4.9:1 | 58 | 76.2 | 34 | 28.6 | 1.19 | 16.1 |
| Present study | Gujarat | 2020 | 416 | 5.2:1 | 58.15 | 79.8 | 43.8 | 34.9 | 1.26 | 12.02 |
ADC: Adenocarcinoma, SCLC: Small-cell lung cancer, SqCC: Squamous cell carcinoma
| Study | Place (year) | Bronchoscopic diagnostic yield (%) | Others | |||||
| EBB | TBLB | TBNA | BAL | Brushing | Overall | |||
| Schreiber and McCrory[24] | USA (2003) | 74 | 46 | 56 | 48 | 59 | 69-88 | 33-62 |
| Roth et al.[25] | Norway (2008) | 60.7 | 40.8 | 6.9 | 23 | 44.4 | – | |
| Rivera et al.[26] | Ohio (2013) | 74 | 57-63 | 65 | 43 | 54-61 | 78 | 88-92 |
| Patil and Rujuta[27] | Latur (2017) | 84.55 | 26.22 | 62.6 | – | – | 71.95 | – |
| Present study | Gujarat (2020) | 87.8 | 64.1 | 53.2 | 45.5 | 45.1 | 69.9 | 85.7 |
BAL: Broncho alveolar lavage, EBB: Endobronchial biopsy, TBLB: Trans bronchial lung biopsy, TBNA: Trans bronchial needle aspiration
Limitation of the study
This study has not included details of pleural fluid analysis and thoracoscopic analyzed patients. Advanced methods of diagnosis such as fluoroscopy, endobronchial ultrasound, virtual bronchoscopy navigation, and electromagnetic navigational bronchoscopy were not utilized due to unavailability at study centers. The study population represents only the west zone of India.
CONCLUSION
Lung cancer is mainly diagnosed in older patients and in the advanced pathological stage. The incidence of lung cancer is higher among males and smokers. ADC is the most common pathology to be encountered in lung cancer. Bronchoscopy is the initial tool for the diagnosis of lung cancer, shows a high yield for centrally located lung mass.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Access this article online | |
Quick Response Code:
|
Website: |
REFERENCES
1. GLOBOCAN 2020: New Global Cancer Data. Uicc.org. Available from: https://www.uicc.org/news/globocan-2020-new-global-cancer-data. [Last accessed on 2022 Aug 3].
2. Iarc.fr. Available from: https://gco.iarc.fr/today/data/factsheets/populations/900-world-fact-sheets.pdf. [Last accessed on 2022 Aug 3].
3. Iarc.fr. Available from: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. [Last accessed 2022 Aug 3].
4. Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al. Cancer statistics, 2020: Report from national cancer registry programme, India. JCO Glob Oncol 2020;6:1063-75.
5. Valaitis J, Warren S, Gamble D. Increasing incidence of adenocarcinoma of the lung. Cancer 1981;47:1042-6.
6. Mohan A, Latifi AN, Guleria R. Increasing incidence of adenocarcinoma lung in India: Following the global trend? Indian J Cancer 2016;53:92-5.
7. Mohan A, Garg A, Gupta A, Sahu S, Choudhari C, Vashistha V, et al. Clinical profile of lung cancer in North India: A 10-year analysis of 1862 patients from a tertiary care center. Lung India 2020;37:190-7.
8. Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG. Introduction to the 2015 world health organization classification of tumors of the lung, pleura, thymus, and heart. J Thorac Oncol 2015;10:1240-2.
9. Groome PA, Bolejack V, Crowley JJ, Kennedy C, Krasnik M, Sobin LH, et al. The IASLC lung cancer staging project: Validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol 2007;2:694-705.
10. Edges S, Greene F, Byrd DR, Brookland RK. AJCC Cancer Staging Manual. New York, NY: Springer; 2016.
11. Sahin F, Yildiz P. Radiological, bronchoscopic and histopathologic characteristics of patients with primary lung cancer in Turkey (2006-2009). Asian Pac J Cancer Prev 2011;12:1947-52.
12. Prasad R, James P, Kesarwani V, Gupta R, Pant MC, Chaturvedi A, et al. Clinicopathological study of bronchogenic carcinoma. Respirology 2004;9:557-60.
13. Rawat J, Sindhwani G, Gaur D, Dua R, Saini S. Clinico-pathological profile of lung cancer in Uttarakhand. Lung India 2009;26:74-6.
14. Sheikh S, Shah A, Arshed A, Makhdoomi R, Ahmad R. Histological pattern of primary malignant lung tumours diagnosed in a tertiary care hospital: 10 year study. Asian Pac J Cancer Prev 2010;11:1341-6.
15. Singh N, Aggarwal AN, Gupta D, Behera D, Jindal SK. Quantified smoking status and non-small cell lung cancer stage at presentation: analysis of a North Indian cohort and a systematic review of literature. J Thorac Dis 2012;4:474-84.
16. Dey A, Biswas D, Saha SK, Kundu S, Kundu S, Sengupta A. Comparison study of clinicoradiological profile of primary lung cancer cases: An Eastern India experience. Indian J Cancer 2012;49:89-95.
17. Noronha V, Dikshit R, Raut N, Joshi A, Pramesh CS, George K, et al. Epidemiology of lung cancer in India: Focus on the differences between non-smokers and smokers: A single-centre experience. Indian J Cancer 2012;49:74-81.
18. Krishnamurthy A, Vijayalakshmi R, Gadigi V, Ranganathan R, Sagar TG. The relevance of “Nonsmoking-associated lung cancer” in India: A single-centre experience. Indian J Cancer 2012;49:82-8.
19. Malik PS, Sharma MC, Mohanti BK, Shukla NK, Deo S, Mohan A, et al. Clinico-pathological profile of lung cancer at AIIMS: A changing paradigm in India. Asian Pac J Cancer Prev 2013;14:489-94.
20. Murali AN, Radhakrishnan V, Ganesan TS, Rajendranath R, Ganesan P, Selvaluxmy G, et al. Outcomes in lung cancer: 9-year experience from a tertiary cancer center in India. J Glob Oncol 2017;3:459-68.
21. Kaur H, Sehgal IS, Bal A, Gupta N, Behera D, Das A, et al. Evolving epidemiology of lung cancer in India: Reducing non-small cell lung cancer-not otherwise specified and quantifying tobacco smoke exposure are the key. Indian J Cancer 2017;54:285-90.5.
22. Bhattacharyya SK, Mandal A, Deoghuria D, Agarwala A, Ghoshal AG, Dey SK. Clinico-pathological profile of lung cancer in a tertiary medical centre in India: Analysis of 266 cases. http://www.academicjournals.org/JDOH: Journal of Dentistry and Oral Hygiene 2011;330-3. [Last accessed on 2022 Aug 3].
23. Furrukh M, Al-Moundhri M, Zahid KF, Kumar S, Burney I. Customised, individualised treatment of metastatic non-small-cell lung carcinoma (NSCLC). Sultan Qaboos Univ Med J 2013;13:202-17.
24. Schreiber G, McCrory DC. Performance characteristics of different modalities for diagnosis of suspected lung cancer: Summary of published evidence. Chest 2003;123:115S-28S.
25. Roth K, Hardie JA, Andreassen AH, Leh F, Eagan TM. Predictors of diagnostic yield in bronchoscopy: A retrospective cohort study comparing different combinations of sampling techniques. BMC Pulm Med 2008;8:2.
26. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of chest physicians evidence-based clinical practice guidelines. Chest 2013;143 Suppl 5:S142-65.
27. Patil S, Rujuta A. 'Bronchoscopic characterization of lesions': Significant impact on lung cancer diagnosis with use of transbronchial needle aspiration (TBNA) in comparison to conventional diagnostic techniques (CDTs). Clin Cancer Invest J 2017;6:239.
________________________
© 2022 Indian Journal of Respiratory Care. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.