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J. Singh
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P2.04 - Poster Session/ Biology, Pathology, and Molecular Testing (ID 234)
- Event: WCLC 2015
- Type: Poster
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.04-043 - A Successful Case in Which Electromagnetic Navigation Bronchoscopy Identified an EGFR Mutation in Small Peripheral Lung Lesions (ID 2447)
09:30 - 09:30 | Author(s): J. Singh
- Abstract
Background:
Our institution participated in a Phase I National Trial that treats patients with advanced NSCLC. Clinical enrollment not only required repeat biopsy of tissue for histopathological analysis and molecular testing, but the target lesions were technically challenging due to size, number of lesions, risk, and and time constraints. Utilization of electromagnetic navigation bronchoscopy (ENB) was used to enroll a patient in a clinical trial in which multiple target lesions were identified, but the only viable target lesion was a mere 6mm in diameter in the periphery of the lung.
Methods:
A 54 year old Asian male showed disease progression in a follow-up chest CT after 9 months of treatment with Erlotinib, suggesting that an acquired resistance to Erlotinib had developed after an initial successful response. Additional tissue specimens were needed to determine if the patient was eligible to participate in a Phase I National Clinical Trial that is attempting to prevent EGFR mutations from acquiring resistance mechanisms. An electromagnetic navigational bronchoscopy (ENB™) guided forceps biopsy tool was utilized to obtain tissue samples from 3 separately identified lesions. Figure 1
Results:
All 3 lesions were successfully navigated and tissue samples were all adequate for molecular testing. NSCLC favoring adenocarcinoma was diagnosed for all 3 sites. However, the admixture of cell types (bronchial epithelial, inflammatory cells, etc) meant that only the smallest 6mm peripheral right middle lobe lesion tissue sample biopsy could be used for this specific trial. Based on these pathology results this patient was enrolled.
Conclusion:
Newer minimally invasive biopsy technologies such as ENB™ guidance can facilitate biopsies of multiple pulmonary sites in one procedure; such procedures are safe and feasible in a community based setting. Moreover, these procedures are increasingly important to meet the expanding needs for advanced histological and molecular testing in oncology. This procedure enabled us to enroll this patient in a Phase I National Trial that may potentially address his acquired resistance to Erlotinib treatment.
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P3.03 - Poster Session/ Treatment of Locoregional Disease – NSCLC (ID 214)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/09/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P3.03-011 - General Anesthesia Is Not Required for Safe, Accurate Endoscopic Diagnosis of Malignant and Non-Malignant Disease in the Mediastinum (ID 1303)
09:30 - 09:30 | Author(s): J. Singh
- Abstract
Background:
Since its introduction in the early to mid 2000’s, endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) of mediastinal lymph nodes has been shown to be superior to “blind” TBNA for the diagnosis of malignancy and sarcoidosis in multiple studies. There is no consensus, however, regarding the optimal method of procedural sedation for EBUS. The purpose of this retrospective study was to determine differences in sampling accuracy and safety between a group of patients undergoing EBUS with moderate sedation and a group with general anesthesia.
Methods:
A retrospective chart review was performed of 51 consecutive patients undergoing convex probe EBUS-guided TBNA over a six-month period at a large, community-based referral hospital. Fifteen procedures were performed under general anesthesia and 36 with moderate sedation using midazolam and fentanyl after topical preparation of the upper airway with lidocaine. Twenty nodal biopsies were performed on the 15 general anesthesia patients, and 47 biopsies were performed on the 36 patients from the moderate sedation group. Rapid on-site cytologic evaluation (ROSE) was used for most cases.
Results:
No statistically significant difference was found in any measured variable between the two groups, specifically sample adequacy (85% in the general anesthesia [GA] group vs. 83% in the moderate sedation [MS] group; p = 1.0; 95% confidence interval (CI), -17.0 to 21.0%) or frequency of adverse events (6.7% GA vs. 5.6% MS; p = 1.0; 95% confidence interval (CI), -13.6 to 15.8%). There was no significant difference in the mean size of lymph nodes biopsied (16.4 mm GA vs. 18.3 mm MS; p = 0.28). Additionally, there was no difference in the proportion of biopsies taken from individual nodal stations or in the numbers and types of diagnoses made between the two groups. Adverse events were mild and included self-limited, non-cardiac chest pain in a patient receiving GA, and two episodes of desaturation in the MS group that resolved with temporary interruption of the procedure.
Conclusion:
As payor scrutiny and emphasis on quality, cost-effective health care increases, convex probe EBUS-guided biopsy utilizing moderate sedation remains an effective, accurate method of diagnosing malignant and non-malignant disease in the mediastinum without the added cost of general anesthesia and without compromising patient safety. Certainly general anesthesia can be an invaluable resource for bronchoscopic procedures in high-risk patients with morbid obesity, sleep apnea, heavy home narcotic or sedative use and other complex comorbidities, but healthcare facilities without anesthesia services can acquire and effectively employ convex EBUS technology with confidence.
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P3.06 - Poster Session/ Screening and Early Detection (ID 220)
- Event: WCLC 2015
- Type: Poster
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:
- Coordinates: 9/09/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P3.06-025 - Electromagnetic Navigation Bronchoscopy in the Evaluation of Lung Lesions: The Carolinas Medical Center Experience (ID 2442)
09:30 - 09:30 | Author(s): J. Singh
- Abstract
Background:
Electromagnetic Navigation Bronchoscopy (ENB) is a relatively new minimally invasive bronchoscopic procedure that can be used to diagnose lung cancer, allowing bronchoscopists to (1) navigate towards peripheral lung lesions unreachable by a traditional bronchoscope, and (2) to utilize tools that can potentially obtain tissue samples large enough to perform advanced diagnostic and molecular testing. Here we share the experience of ENB at a large community-based hospital, aiming to better understand the diagnostic ability of ENB as well as possibly identify success factors for the biopsy methodology.
Methods:
Between September, 2012 and June, 2014, ENB was utilized in 138 cases to diagnose pulmonary lesions. Retrospective chart review was performed to access patient personal demographic information and disease-specific information. True positive diagnostic procedures were defined as those with a pathologically confirmed cancer diagnosis. True negative procedures were defined as those in which the lesions were not cancerous and had either resolved on radiological follow-up or have been stable over a period of 1 year. We assessed diagnostic yield percentages, lesion characteristics such as size and location, histological and staging characteristics of the tumor, outcomes of diagnostic tools, and size-tool correlation.
Results:
The ENB System carried an overall diagnostic yield of 75% with a sensitivity was 71.8% and specificity of 100%. 79% represented true positive results and 21% false negatives. Of the True Positives, 93% were non-small cell of which 73.6% were adenocarcinoma or had adenocarcinoma features. Of the latter, 82.1% of the adenocarcinomas diagnosed had enough tissue in the biopsy specimen for molecular testing. Of the negative results, 23% were later proven within 3-4 months of the initial biopsy and 77% after 3-4 months. The majority of cases attempted were stage I and II, with more success with lesions of larger tumor volume (greater than 500 mm[2]). Of the four tools used for biopsy sampling: lavage, brush, fine needle aspiration (FNA) and forceps, the brush had the highest true value percentage at 82.6%, followed by forceps at 80.7%. Lesions located in the right lung produced a greater percentage of true diagnoses with the right middle lobe giving an 87.5% yield while having the lowest percentage of false diagnoses at 12.5%. Risks for the procedure was 3.6% with 4 patients having pneumothorax and 1 patient with hemorrhage requiring intervention
Conclusion:
ENB can be successfully used to diagnose lung cancer in a community setting with a minimally invasive approach, and do so with reasonable accuracy and minimal risk. Moreover, tissue yields from this procedure were sufficient in over 80% of adenocarcinoma cases for molecular testing. Success factors include greater lesion size and the deployment of multiple diagnostic tools to enhance diagnostic yield. Further study is needed to determine other success factors.
