ROLE OF THE RESPIRATORY PHYSICIAN IN LUNG CANCER

WORK UPDR DAMOON ENTESARI-TATAFI

RESPIRATORY PHYSICIAN

BALLARAT HEALTH SERVICE

CONFLICT OF INTEREST

• IN THE PROCESS OF COMPLETING BUSINESS CASE PROPOSAL FOR ENDOBRONCHIAL

ULTRASOUND (EBUS) AT BALLARAT BASE HOSPITAL

OUR ROLE

• CLINICAL ASSESSMENT

• PARENCHYMAL LUNG DISEASE: PULMONARY NODULES AND MASSES

• THORACIC ADENOPATHY

• PLEURAL DISEASE: NODULARITY, MASSES, EFFUSION AND THICKENING

• DIAGNOSTIC EVALUATION

• BRONCHOSCOPY

• PLEURAL ULTRASOUND AND THORACOCENTESIS

• ASSESSMENT PATIENT FITNESS: PRE-OPERATIVE/ PRE-RADICAL TREATMENT

• MANAGEMENT OF PULMONARY COMORBIDITIES AND COMPLICATIONS

• DO NOT DIRECTLY INVOLVED IN DEFINITIVE TREATMENT

• REMOVES POTENTIAL CONFLICT OF INTEREST FOR PREFERRED TREATMENT MODALITY

DIAGNOSTIC INVESTIGATIONS

• BRONCHOSCOPY

• RIGID – WHEN CONTROL OF AIRWAY IMPORTANT (PERFORMED BY SURGEONS)

• STANDARD FLEXIBLE

• ENDOBRONCHIAL ULTRASOUND (EBUS) – LINEAR AND RADIAL

• CRYOBIOPSY – EMERGING ROLE IN LUNG ONCOLOGY DIAGNOSTICS

DIAGNOSTIC INVESTIGATIONS

• BRONCHOSCOPY

• RIGID – WHEN CONTROL OF AIRWAY IMPORTANT (PERFORMED BY SURGEONS)

• STANDARD FLEXIBLE

• ENDOBRONCHIAL ULTRASOUND (EBUS) – LINEAR AND RADIAL

• CRYOBIOPSY – EMERGING ROLE IN LUNG ONCOLOGY DIAGNOSTICS

EBUS

• PROCEDURE REQUIRES

• CONSENT

• FASTING FOR MINIMUM 6 HOURS PRE-PROCEDURE

• TRANSPORTATION POST PROCEDURE

• CONSIDERATIONS

• CAN BE PERFORMED ON ASPIRIN

• CLOPIDOGREL AND ANTICOAGULATION SHOULD BE WITHHELD

• LESS BLEEDING RISK THAN ENDOBRONCHIAL AND ESPECIALLY TRANSBRONCHIAL BIOPSY

• GREATER BLEEDING RISK THAN STANDARD BRONCHOSCOPY

LINEAR EBUS

• INDICATIONS:

• HILAR OR MEDIASTINAL ADENOPATHY ACCESSIBLE BY EBUS

• NEEDS CT CHEST +/- PET FOR PROCEDURE PLANNING

• PARENCHYMAL LUNG LESION IMMEDIATELY ADJACENT TO AIRWAY ACCESSIBLE BY EBUS

• ADENOPATHY OR MASS ADJACENT TO OESOPHAGUS (EUS-B)

• AVAILABLE AT RMH

• ADVANTAGES

• DIAGNOSE AND STAGE IN SINGLE PROCEDURE

• VISUALISE LESIONS EXTERNAL TO THE AIRWAY IN REAL TIME

• BIOPSIES CAN BE TAKEN IN REAL TIME

• WHEN COMBINED WITH RAPID ON SITE CYTOLOGICAL EVALUATION CAN REDUCE NUMBER OF BIOPSIES AND PROCEDURE TIME WHILE MAINTAINING BIOPSY YIELD

• LIMITATIONS

• LARGE SCOPE DIFFICULT TO MANEUVER INTO DISTAL AIRWAYS

• CAN COMBINE WITH STANDARD BRONCHOSCOPY BUT REQUIRES SEPARATE SCOPE

LINEAR EBUS – LYMPH NODE ANATOMY

• TYPICALLY ACCESSIBLE LYMPH NODE

GROUPS

• LYMPH NODES SAMPLED USUALLY LARGER

THAN 10MM

• CAN SAMPLE LYMPH NODES AS SMALL AS

5MM BUT TECHNICALLY CHALLENGING

• WHEN PET POSITIVE

LINEAR EBUS – PET SCAN

ACCESSIBLE 4R POTENTIALLY INACCESSIBLE

LINEAR EBUS• PERFORMED UNDER DEEP SEDATION WITH TOPICALISED AIRWAY

• REQUIRES A CUSTOMIZED BRONCHOSCOPE WITH MOUNTED

ULTRASOUND AT TIP

• COVERED WITH A BALLOON THAT IS INFLATED WITH SALINE TO IMPROVE

COUPLING BETWEEN US PROBE AND BRONCHIAL WALL

• SCOPE LARGER THAN STANDARD BRONCHOSCOPE SO ORAL

APPROACH REQUIRED

• NEEDLE EMERGES INLINE WITH ULTRASOUND TO ALLOW FOR REAL

TIME VISUALIZATION AND BX

• US APPEARANCE MAY PREDICT PROBABILITY OF MALIGNANT

INVOLVEMENT BUT BIOPSY REQUIRED FOR CONFIRMATION

LINEAR EBUS

• SENSITIVITY 90-95% ACROSS A NUMBER OF STUDIES FOR MALIGNANCY

• COMPARED WITH CT AND PET USUALLY 10-15% INCREMENTAL SENSITIVITY

• REDUCES NEED FOR INVASIVE MEDIASTINOSCOPY

• SURGICAL PROCEDURE

• SENSITIVITY AROUND 85% IN SARCOIDOSIS

• REDUCES NEED FOR TRANSBRONCHIAL BIOPSY WHICH INCREASE RISK OF PNEUMOTHORAX

RADIAL EBUS

• INDICATIONS:

• DIAGNOSTIC SAMPLING OF PERIPHERAL LUNG NODULES

• ADVANTAGES

• ALLOWS FOR IMAGE GUIDED LOCALISATION OF PERIPHERAL LUNG NODULES BEYOND THE WHAT CAN BE ACCESSED BY STANDARD

BRONCHOSCOPY

• ULTRASOUND CONFIRMS LOCATION OF LESION AND GUIDE-SHEATH LEFT IN SITU TO ALLOW SAMPLING FROM SAME SITE

• CAN BE COMBINED WITH ELECTROMAGNETIC NAVIGATION SYSTEM

• AVAILABLE AT RMH

• CAN BE COMBINED WITH IMAGE INTENSIFIER TO CONFIRM LESION LOCATION AND REDUCE RISK OF PNEUMOTHORAX

• LIMITATIONS

• LESION MUST HAVE AIRWAY RUNNING THROUGH IT

• YIELD FOR SMALLER PERIPHERAL LESIONS SIGNIFICANTLY REDUCED

RADIAL EBUS – TYPICAL CASE

RADIAL EBUS• PERFORMED UNDER DEEP SEDATION WITH TOPICALISED AIRWAY

• UTILISES STANDARD BRONCHOSCOPE WITH RADIAL EBUS PROBE

PASSED THROUGH WORKING CHANNEL

• GUIDE SHEATH UTILIZED TO ACT AS LOCATION MARKER

• BIOPSY, BRUSH AND WASHING OBTAINED FROM PREDETERMINED

SITE

• NASAL OR ORAL APPROACH POSSIBLE

• RAPID ON-SITE CYTOLOGICAL EVALUATION LESS USEFUL AS

MALIGNANT AND EPITHELIAL CELLS EASILY CONFUSED

RADIAL EBUS

• DIAGNOSTIC SENSITIVITY FOR PERIPHERAL LUNG MASSES:

• RADIAL EBUS > 70%

• STANDARD BRONCHOSCOPY 20% WITH WASHING ALONE

• STANDARD BRONCHOSCOPY WITH IMAGE INTENSIFIER APPROXIMATELY 40-50%

• CT GUIDED BIOPSY 85-95%

• UP TO 20% RISK OF PNEUMOTHORAX DEPENDING ON LOCATION OF LESION

• COMPLICATION RATE ALSO LOWER <1% VS ~5% FOR STANDARD TRANSBRONCHIAL BIOPSIES

SUMMARY

• BRONCHOSCOPY AND CT GUIDED BIOPSY REMAIN THE CORNER STONES OF LUNG CANCER

DIAGNOSIS

• LINEAR EBUS HAS ALLOWED FOR CONCURRENT STAGING AND DIAGNOSIS OF LUNG CANCER

• RADIAL EBUS HAS IMPROVED SAMPLING OF LESIONS TOO CENTRAL FOR CT GUIDED BIOPSY AND TOO

PERIPHERAL FOR STANDARD BRONCHOSCOPY

• BOTH TECHNIQUES HAVE EXCELLENT DIAGNOSTICS YIELD AND SAFETY PROFILE

• EBUS IS WIDELY AVAILABLE INCLUDING AT LARGE REGIONAL CENTRES:

• GEELONG

• ALBURY WODONGA

• ?BALLARAT… WATCH THIS SPACE

QUESTIONS?

• THANK YOU!