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N. Kurimoto
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ES 07 - Recent Advances in Diagnostics and Interventional Bronchoscopy (ID 516)
- Event: WCLC 2017
- Type: Educational Session
- Track: Pulmonology/Endoscopy
- Presentations: 4
- Moderators:Stephen Lam, N. Kurimoto
- Coordinates: 10/18/2017, 11:00 - 12:30, Room 503
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ES 07.01 - Endoscopic Staging of Lung Cancer (ID 7610)
11:00 - 11:20 | Presenting Author(s): Kazuhiro Yasufuku
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Endoscopic Staging of Lung Cancer Kazuhiro Yasufuku During the management of patients with lung cancer, accurate lymph node staging is important not only to determine the prognosis but also to decide the most suitable treatment plan. Non-invasive staging such as computed tomography (CT) and positron emission tomography (PET) indicate size and metabolic activity, respectively. However imaging alone is inaccurate and therefore tissue sampling is the preferred and most reliable. Surgical staging by mediastinoscopy has been the gold standard for mediastinal lymph node staging but requires general anesthesia and complications cannot be ignored. Endoscopic ultrasound techniques provide a minimally invasive alternative for surgical staging and have become available for oncologists around the world. The current available endoscopic ultrasound techniques for mediastinal staging include transesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Both procedures are performed in an outpatient setting under local anesthesia. EUS-FNA is a sensitive and safe method of evaluating the inferior mediastinal nodes (stations 7, 8, and 9) and some parts of the anterior mediastinal nodes if the lymph nodes are accessible from the esophagus. However, in spite of the strength of EUS-FNA for evaluating the inferior mediastinal nodes, its ability to evaluate lesions anterior to the trachea is limited. On the other hand, EBUS-TBNA has reach to the paratracheal and subcarinal (stations 2R, 2L, 4R, 4L, 7), as well as the N1 lymph nodes (stations 10, 11, 12). In experienced hands, EBUS can be used through the esophagus for a EUS-like approach to sample inferior mediastinal lymph nodes. With the transvascular approach, AP window lymph nodes (station 5) can be sampled by EUS-FNA and/or EBUS-TBNA. Specialized centers have reported the sampling of station 6 via EUS-FNA. Thus, EUS-FNA and EBUS-TBNA are complementary methods for lymph node staging in lung cancer and most of the mediastinum and the hilum can be evaluated with these endoscopic procedures beyond the reach of mediastinoscopy. Based on the current evidence, EBUS-TBNA and EUS-FNA presents a minimally invasive endoscopic procedure of choice for mediastinal staging of NSCLC with discrete N2 or N3 lymph node enlargement, provided negative results are confirmed by surgical staging. When combined the techniques offer safe and accurate assessment of mediastinum, with accuracy surpassing that of the pervious gold standard – cervical mediastinoscopy. EBUS-TBNA and/or EUS-FNA can also be repeated with ease and have been used for mediastinal restaging in patients who underwent neoadjuvant therapy in preparation for definitive surgical intervention. New size needles are now available for sampling of the lymph nodes during EBUS-TBNA including 25-gauge and 19-gauge needles. Smaller needles may provide greater reach with good quality samples, whereas larger 19-gauge needle may provide bigger tissue for histological evaluation of the lymph nodes samples. There are limitations of using cytological samples obtained during EBUS-TBNA or EUS-FNA for PD-L1 expression. The use of the 19-gauge needle may solve this problem.
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ES 07.02 - Guided Bronchoscopy for Peripheral Lung Nodules (ID 7611)
11:20 - 11:40 | Presenting Author(s): Takehiro Izumo
- Abstract
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Abstract:
In the past several years, X-ray fluoroscopy had been commonly employed to determine the lung field during transbronchial biopsy (TBB); however, precise localization of a PPL has not always been possible leading to low diagnostic yield. For ground glass opacities (GGOs), the value of X-ray fluoroscopy even becomes less. The value of virtual X-ray fluoroscopy and CT fluoroscopy has potential but remains to be known. The advent of endobronchial ultrasound (EBUS) has dramatically increased precise bronchoscopic confirmation of the location of a PPL before sampling. In particular, the radial probe EBUS is used to indicate that a lesion has been reached. For solid peripheral pulmonary lesions (PPLs), Kurimoto et al have described three major types of echogenicities that might differentiate between benignity and malignancy. For GGOs, we have observed constant radial-EBUS patterns that we called blizzard and mixed blizzard signs. Currently, several acquired resistance mechanisms and rare driver oncogenes are identified in non-small cell lung cancer (NSCLC) relapses. Re-biopsy increases valuable information to guide treatment strategies, but the utility and feasibility of bronchoscopic re-biopsy especially endobronchial ultrasound (EBUS) guided re-biopsy has not been investigated. We recently reported the utility of bronchoscopic (EBUS-guided) re-biopsy for detecting the mutation in NSCLC. Re-biopsy by both EBUS-TBNA and EBUS-GS were useful and safe sampling procedures for mutation analysis of EGFR-TKI resistant NSCLC. Another alternative approach, specifically liquid biopsy, now present as a crucial point in the field. Liquid biopsy has grown in importance because the genetic profile of tumors can affect how well they respond to a certain treatment. A recent paper showed that the concordance between re-biopsy and liquid biopsy, including plasma DNA and circulating tumor cell, was 57–60%. The usefulness of monitoring T790M status in liquid biopsy was already reported. Although liquid biopsy has the potential to detect new mutations after chemotherapy, several reports have demonstrated some difficulties in detecting tumor-derived mutations in plasma. Therefore, liquid biopsy and re-biopsy may be considered to be complementary methods of mutation analysis. I would like to share our data and actual cases in this talk. Figure 1Figure 2
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ES 07.03 - Bronchoscopic Management of Central Airway Obstruction (ID 7612)
11:40 - 12:00 | Presenting Author(s): Hojoong Kim
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Introduction: Malignant airway obstruction can result from primary airway tumors, extension of adjacent primary tumors, or metastatic tumors. Partial or complete airway obstruction can deteriorate functional status of patients and result in impending respiratory failure. Malignant airway obstruction is considered to be one of the most distressing causes of morbidity and mortality in lung cancer patients. Bronchoscopic intervention can provide immediate relief from suffocation, improve general condition, and provide a bridge, allowing time for additional treatment such as surgery, radiation, or chemotherapy in patients suffering from malignant airway obstruction. Indication: Any patients who suffer from respiratory distress due to central airway obstruction are indicated for bronchoscopic intervention. However, patients should tolerate the morbidity of intervention, the length of the airway obstruction less than 4cm, and the duration of obstruction less than 2 month due to the technical limitation. Method: Due to it is safe from massive hemoptysis and respiratory failure, most experienced bronchoscopists prefer rigid bronchoscopy under general anesthesia, using intravenous propofol injection. After the induction of anesthesia, the patients are intubated with a rigid bronchoscope tube and a flexible bronchoscope is introduced through the rigid bronchoscope tube, and the narrowed central airway was evaluated. In every case, the obstructed airway is dilated gently using an 10 mm rigid bronchoscope tube initially and then progressively larger bronchoscope tubes until an adequate airway caliber was established. When indicated, a controlled radial expansion balloon is used to enlarge the airway sufficiently to allow bronchoscopic dilatation. Any intraluminal mass is removed mechanically using rigid bronchoscopic forceps or a snare. Frequently, a neodymium-yttrium aluminum garnet (Nd-YAG) or diode laser is used to ablate the residual endobronchial tumor or to cauterize the tumor bed after most of the tumor had been excised. After mechanical dilatation, the airway is maintained by inserting a silicone stent (Dumon-style stent) in patients whose airway is not maintained due to extrinsic compression or malacia. The silicone stents are inserted through the rigid bronchoscope using a standard Dumon technique. Outcome: In experienced center, the overall success rate is more than 90% after the emergency bronchoscopic intervention. A successful outcome is accompanied by subjective improvement in the symptoms and radiographic findings. After stabilizing the airway with the bronchoscopic treatment, favorable outcome is expected if additional definitive therapy can be applied, such as surgery, radiation, or chemotherapy. Nowadays, bronchoscopic intervention can achieve prolonged survival with sustained significant improvement of quality of life. Complications: Tracheal perforation, massive bleeding, respiratory failure and cardiac arrhythmia can develop after bronchoscopic intervention. However, the overall complication rate is not over 5% in experienced center. Conclusion: Bronchoscopic intervention in patients with malignant airway obstruction is helpful for the palliation the airway, allowing the multimodality therapeutic approach and prolonging the life of the patients. References 1. Jeon K, Kim H, Yu CM, et al. Rigid bronchoscopic intervention in patients with respiratory failure caused by malignant central airway obstruction. J Thorac Oncol 2006;1:319-323. 2. Cavaliere S, Venuta F, Foccoli P, et al. Endoscopic treatment of malignant airway obstructions in 2,008 patients. Chest 1996;110:1536-1542. 3. Han CC, Prasetyo D, Wright GM. Endobronchial palliation using Nd:YAG laser is associated with improved survival when combined with multimodal adjuvant treatments. J Thorac Oncol 2007;2:59-64. 4. Chhajed PN, Eberhardt R, Dienemann H, et al. Therapeutic bronchoscopy interventions before surgical resection of lung cancer. Ann Thorac Surg 2006;81:1839-1843. 5. Stratakos G, Gerovasili V, Dimitropoulos C, et al. J Cancer. 2016;25: 794-802.
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ES 07.04 - Endoscopic Options for Solitary Pulmonary Nodules (ID 7613)
12:00 - 12:20 | Presenting Author(s): Stephen Lam
- Abstract
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World-wide, aside from men in France, Spain and the Netherlands, peripherally located adenocarcinomas have now overtaken squamous cell carcinoma as the predominant lung cancer cell type. With the implementation of lung cancer screening programs using low dose CT and increasing use of CT imaging for clinical investigations, a large number of people are found to have lung nodules. In contrast to symptomatic lung cancer, the size of screening CT detected or incidental lung nodules suspicious of malignancy is much smaller. Over 75% of screening CT detected lung cancers are ≤20 mm with 20% to 47% of the lung cancers found in the first screening CT and 33% to 62% of lung cancers found in annual repeat screening CT are ≤10 mm.[1-4] Because of the small size of these lesions, currently only 20% to 34% of screening CT detected lung cancers are diagnosed by endoscopy. The diagnostic yield of bronchoscopic biopsies is modest.[1,2] In the real world setting, even with advanced bronchoscopic methods such as navigation bronchoscopy and radial ultrasound, the diagnostic yield of peripheral lung lesions is less than 60%.[5,6] Several factors account for the suboptimal diagnostic yield. The diameter of the airways leading to the lesion may be smaller than the 1.4 mm diameter radial EBUS probe. The lesion may be eccentric rather than perpendicular to the biopsy forceps. Removable of the imaging probe from a guide sheath and re-insertion of biopsy forceps or needle may cause displacement or migration of the guide sheath to a different airway. To improve the diagnostic accuracy, other methods are being developed for endoscopic detection and biopsy of peripheral lung lesions ≤20 mm. Bronchoscopic transparenchymal approach to access peripheral lung nodules from more central airways and real time flouroscopic transbronchial guidance systems are under evaluation.[7,8] Flexible 21G peripheral needles are becoming commercially available for transbronchial aspiration or core biopsy. Small optical imaging probes < 0.5 mm that can be inserted within a 21G needle to confirm abnormal pathology in real time using optical frequency domain imaging[9,10] or diffuse reflectance spectroscopy before taking a biopsy. These newer endoscopic approaches hold promise to improve diagnostic accuracy while maintaining the advantage of lower complication rates such as pneumothorax and bleeding compares to CT guided transthoracic lung biopsy. References 1. National Lung Screening Research Team, Church TR, Black WC, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013 May 23;368(21):1980-91. 2. Aberle DR, DeMello S, Berg CD, et al. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med 2013; 369(10):920-31. 3. McWilliams A, Tammemagi MC, Mayo et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013;369:910-9. 4. Horeweg N, van Rosmalen J, Heuvelmans MA, et al. Lung cancer probability in patients with CT-detected pulmonary nodules: a prespecified analysis of data from the NELSON trial of low-dose CT screening. Lancet Oncol. 2014 Nov;15(12):1332-41. 5. Ost DE, Ernst A, Lei X, et al. AQuIRE Bronchoscopy Registry. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Respir Crit Care Med. 2016 Jan 1;193(1):68-77. 6. Ali MS, Trick W, Mba BI, et al. Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology. 2017; 22(3):443-453. 7. Herth FJ, Li S, Jiayuan Sun J, Nader D. Bronchoscopic TransParenchymal Nodule Access: Evaluation of safety and feasibility of Archimedes System. Am J Respir Crit Care Med 2017;195:A7597. 8. Stoy SP, Whitten PE, Al-Zubaidi A, Hogarth K. Bronchoscopic peripheral lung nodule navigation by a novel Live fluoroscopic overlay guidance technology. Am J Respir Crit Care Med 2017;195:A2865. 9. Tan KM, Shishkov M, Chee A, et al. Flexible transbronchial optical frequency domain imaging smart needle for biopsy guidance. Biomed Opt Express 2012; 3::1947-1954. 10. Pahlevaninezhad H, Lee AM, A. R, et al. Endoscopic Doppler optical coherence tomography and autofluorescence imaging of peripheral pulmonary nodules and vasculature. Biomedical Optics Express. 2015; 6(10):4191-9.
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