New technologies New technologies FJF Herth AFB, EBUS, EUS, HRCT, OCT, or yet something else…. AFB, EBUS, EUS, HRCT, OCT, or yet something else….

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Presentation transcript:

New technologies New technologies FJF Herth AFB, EBUS, EUS, HRCT, OCT, or yet something else…. AFB, EBUS, EUS, HRCT, OCT, or yet something else….

New technologies New technologies Thoraxklinik-Heidelberg tuberculosis hospital 1895 since 1972 rebuild as clinic for lung diseases 320 beds / 3 departments Thoracic surgeryOncologyPulmonology/ Critical care med. H. DienemannP. DringsFJF Herth

New technologies New technologies ~ 5000 US/year all interventional procedures Endobronchial Ultrasound Thoracoscoy

New technologies New technologies Rigid bronchoscopy

New technologies New technologies

New technologies New technologies

New technologies New technologies

New technologies New technologies IS THIS THE IDEAL BRONCHOSCOPY SUITE? ELECTROCAUTERY CRYOTHERAPY BALOONS MONITORS BI-PLANE DIGITAL PULSE FLUOROSTENTSAUTOFLUORESCENCE ENDOBRONCHIAL ULTRASOUND ARGON PLASMA COAG THORACOSOPY SUPERDIMENSION EPACS MONITORS

New technologies New technologies BASIC SUITE Airway examination BAL Cytologic brushing Endobronchial Biopsy Transbronchial biopsy TBNA ADVANCED SUITE EBUS Autofluorescence External Navigation Electrocautery / APC Cryotherapy PDT Laser Stenting Thoracoscopy

New technologies New technologies Transbronchial needle aspiration......TBNA for friends... What’s your name? S. Gasparini, Heidelberg, 2002

New technologies New technologies Schieppati, 1949 Station 7 nodes Schiessle, 1962 Mediastinal tumors Versteegh & Swierenga, 1969 Determine inoperability for lung cancer Wang,1978 Mediastinal LN staging Rigid Wang, Terry,1983 Flexible technique Schieppati. Rev As Med Argent 1949;663:497 Schiessle. J Fr Med Chir Thor 1962;16:551 Wersteegh, Acta Oto-laryng 1963;56:603 Wang et al., ARRD 1978;118:17 Wang et al., ARRD 1983;127:344 TBNA

New technologies New technologies TBNA needles 13 mm long 22 gauge 19 / 21 gauge Knowledge of node anatomical position Knowledge of technique TBNA

New technologies New technologies

New technologies New technologies EBB Diagnostic yield > 95 %

New technologies New technologies Adeno-Ca.Chondrohamartom Peripheral lesion

New technologies New technologies Fluoroscopic guided TBBX routine method for diagnostic of solitary pulmonary nodules Disadvantages: Radiation load Yield depending from nodule-size Peripheral lesion

New technologies New technologies TBB

New technologies New technologies TBB

New technologies New technologies yield of TBB % (SPN 2-6 cm) Baaklini et al, Chest, % Gasparini et al., Chest, % Radke et al., Chest, % SPN < 3 cm Herth et al., Pneumologie, % Gacta et al., AJR, % Shiner at al., Thorax, % Radke et al, Chest, %

New technologies New technologies Author N. Patients Sampling instruments Sensitivity Ellis 1975 Cortese, Mc Dougall 1979 Shure, Fedullo 1983 Wang et al 1984 Gasparini et al 1995 Katis et al brushing biopsy brushing + biopsy brushing biopsy brushing + biopsy biopsy transbronchial needle biopsy + needle + brushing biopsy + brushing transbronchial needle biopsy transbronchial needle biopsy + needle washing biopsy transbronchial needle washing+biopsy+needle 42% 68% 69% 40% 46% 60% 36% 52% 69% 25% 68% 53% 69% 75% 24% 38% 62% 70%

New technologies New technologies Technique and results AF Videobronchoscopy Endobronchial ultrasound Low-dose CT Magnifying NBI Optical Coherence

New technologies New technologies

New technologies New technologies <5% of autofluorescence is from epithelium submucosa and cartilage autofluoresce strongly autofluorescence is a characteristic of the upper submucosa, due to depth of penetration of blue light Qu et al. Optical Engineering 1995

New technologies New technologies Autofluorescence

New technologies New technologies AF-BronchsocopyAF-Bronchsocopy Systems comparable Safe 100 – Xillix Pierrad et al, J Bronchol, 2001 D-Light – Xillix Herth et al, Respiration, 2004 Additional examination-time 4-7 minutes

New technologies New technologies StudyBiopsies (n) Preval. Dys/CIS (%) Sensitiv. WL (%) Sensitivity WL+AF (%) Relative Sensitivity Lam ,3 Khanavkar ,5 Vermylen ,4 Venmans ,6 Kusunoki ,4 Shibuya ,3 Sato ,1 Häußinger ´ ,4 AF-System Published Data

New technologies New technologies AF Bronchoscopy Considerations Points of discussion risk estimation numbers of the individuals studied expertise of the bronchoscopist consistency of pathologist‘s reports numbers ob biopies taken Sutedja et al., Respiration 2003

New technologies New technologies Arguments against AFB useful only in squamous cell (≤30%) „natural history“ unclear Goldstandard ? reduction of mortality? cost-effectiveness rating in workflow of screening ? Mehta AC et al., J Bronchol 2003

New technologies New technologies Management of Early Lung Cancer Evidence-based Clinical Guideline

New technologies New technologies 1mm Chip - technology

New technologies New technologies

New technologies New technologies CIS Dys 3Dys 1+2 Meta EXERA 2/(0,6%) 8/(2,7%)7/(2,3%)1/(0,3%) AF 2/(0,6%) 8/(2,7%)6/(1,9%)5/(1,5%) 21 (7%) visible TU, all detected with both techniques Chipendoscopy vs. AF-Bronchoscopy EXERA BF – 160 (Olympus) vs. D-light (Storz) Herth et al., Chest, 2004

New technologies New technologies Chhajed et al., Eur Respir J, 2005

New technologies New technologies AFI

New technologies New technologies EXERAD-lightAFI Visible Tu9/98/99/9 CIS1/1 Severe dysplasia4/4 Moderate dysplasia2/21/22/2 Mild dysplasia4/52/55/5 metaplasia1/50/54/5 Herth et al., Chest, 2005

New technologies New technologies Breuer at al. Cancer Clin Res 2005

New technologies New technologies New techniques allows better detection Will the identification and treatment of early lung cancer improve the overall mortality from lung cancer ? “How we should treat?” questions

New technologies New technologies Endobronchial Ultrasound

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New technologies New technologies

New technologies New technologies early3.tifearly3.tif Miazyu et al., AJRCCM, 2002

New technologies New technologies Miyazu Y et al., Am J Respir Crit Care Med, 2002

New technologies New technologies Ultrasound controlled puncture 7,5-10 MHz linear-scanner EBUS-TBNA-Scope

New technologies New technologies

New technologies New technologies

New technologies New technologies year N yield Krasnik et al % Yasufuku et al % Yasufuku et al % Rintoul et al % Herth et al % EBUS-TBNA-Scope

New technologies New technologies

New technologies New technologies EUS

New technologies New technologies EUS Authoryear N yield (%) Giovanni et al Silvestri et al Gress et al Wiersma et al Janssen et al Rabe et al Williams et al Fritscher-R. et al Wallace et al Wiersma et al Fritscher-R. et al Annema et al

New technologies New technologies Diagnostic values of EUS-FNA for cancer in the mediastinum (Patients selected by CT) 22 studies with a total number of 1245 patients Sensitivity 0.61–1.00 (median 0.90) Speciﬁcity of 0.71– 1.00 EUS

New technologies New technologies Restaging Betticher et al., JCO, patients 3 cycles Cisplatin/Doxetacel Sugerbaker: ASCO Educational book, 1994

New technologies New technologies EUS-FNA after induction chemotherapy 19 patients with N-2 disease who had been treated with induction chemotherapy Sensitivityspecificity EUS-FNA75%100% Conclusion: EUS-FNA accurate method for restaging of mediastinal lymph nodes after induction therapy in NSCLC Annema et al., Lung Cancer 2003;42:

New technologies New technologies EBUS-TBNA after induction chemotherapy 83 patients with N-2 disease who had been treated with induction chemotherapy Sensitivityspecificity EBUS- TBNA 70%100% Conclusion: EUS-FNA accurate method for restaging of mediastinal lymph nodes after induction therapy in NSCLC Herth et al., ATS 2006, submitted

New technologies New technologies Coin lesions …. <2cm diameter remains a diagnostic dilemma

New technologies New technologies CT Roadmap is Prepared Same Registration Points on CT and body are marked as coordinates System marries CT images to patient’s body

New technologies New technologies Electromagnetic Navigation SuperDimension™ Electromagnetic Navigation SuperDimension™

New technologies New technologies Electromagnetic Navigation SuperDimension™ Electromagnetic Navigation SuperDimension™

New technologies New technologies year N yield Schwarz et al % Becker et al % Stanzel et al % Eberhardt et al % Electromagnetic navigation SuperDimension™ Electromagnetic navigation SuperDimension™ exam time  min Animal trial Feasibilty trial Lerning curve

New technologies New technologies EBUS guided TBB Tumor 1 1, 3 : no image 2 3

New technologies New technologies

New technologies New technologies 3 cm patients (n) EBUS n, (%)17 (80%)23 (79%) Fluorosc n, (%)12 (57%)26 (89%) n.s. p < 0,001 Herth et al., Eur Respir J, 2002 EBUS guided TBB

New technologies New technologies 54 patients, diameter 2,2 cm lesions visible with EBUS 48 (89%) definitive diagnosis 38 (70%) NSCLC 29 TBC 3 Sarcoidosis 2 Harmatoma 2 SCLC 2 undiagnosed SPNs NSCLC10 inflammatory 6 Results Herth et al., Chest, 2006

New technologies New technologies Results Nodule-size: 2,2 cm (R 1,4-3,3) Numbers of biopsies 4,5 (R 3-6) Mean examination time (incl. biopsies): 12,3 min (6-18) 1 pneumothorax

New technologies New technologies Sideview Magnifying videoscope

New technologies New technologies Video image (far sight) Video image (near sight) Magnified video image Fiberscope image

New technologies New technologies Video Bronchscope Magnifying video bronchscope Comparison of video images

New technologies New technologies Shibuya et al., Thorax, 2003 Vasculary pattern allows distinction bronchitis /dysplasia Magnifying video bronchoscope

New technologies New technologies Light Penetration Depth Narrow Band Imaging

New technologies New technologies Broad band filter transmit the light penetrating deeply. Narrow band filter restrict the light penetration within near surface. Narrow Band Imaging

New technologies New technologies It is expected that the correlation of the images between RGB channels will be decrease, and the tissue structure with Z axes will be more clearly reproduce as the color information. B road band filters N arrow band filters Narrow Band Imaging

New technologies New technologies 415nm465nm540nm

New technologies New technologies NBI Conventional

New technologies New technologies Narrow Band Imaging

New technologies New technologies Narrow Band Imaging

New technologies New technologies

New technologies New technologies broadband near-infrared light source emitted light splitted into sample and reference beam reflected beams were recombined interference pattern is produced OCT

New technologies New technologies In vivo imaging of the scattering inherent in tissue Spatial resolution: μm, 10 times better than EUS Up to 2mm from the mucosal surface Non-contact index matching not required; without balloon filed with water

New technologies New technologies 0.75 mm L MMSubM ME 0.75 mm L MM SubM ME C M OCT

New technologies New technologies OCT

New technologies New technologies OCT Hanna et al., J Thorac Cardiovasc Surg, 2005

New technologies New technologies technique not available still ex vivo technique two papers colon cancer one lung paper published OCT

New technologies New technologies

New technologies New technologies Data courtesy of Dr. Inoue, Tokyo Normal mucosa carcinoma

New technologies New technologies prototypes for colonoscopy available first trial shows promising results early cancer sensitifity 97 %, specifity 99% Limitation necessity of fluorescent dyes secretion (image quality) orientation µ-Cosm Kiesslich et al., Gastroenterology, 2004

New technologies New technologies Light Guide Microscope Observation of cilia movement 10 ～ 20 ゜ 20 ～ 30 ゜

New technologies New technologies

New technologies New technologies NETT-trial

New technologies New technologies basics Blocks inspiratory flow to diseased lung regions Reduces hyperinflation Re-directs airflow to healthier lung areas Improved breathing mechanics Physiologic and clinical improvement Potential benefits of LVRS, but with a minimally invasive & potentially reversible approach

New technologies New technologies

New technologies New technologies Emphasys™ Spiration™ Pulmonix™ Watanabe Spigots™ Exhale™

New technologies New technologies

New technologies New technologies Endo - Valves Self-expanding retainer - stabilizes device in airway Flexible seals - conform to bronchial wall - prevent air leak around valve One-way valve - blocks inspiration - allows mucus clearance

New technologies New technologies Emphasys ® 4 feasibility trials VENT trial closed Spiration ® feasibility trial during ERS Pulmonix ® feasibility trial ongoing Spigots feasibilty trial ongoing Bronchus feasibilty trial stpped

New technologies New technologies Venuta et al., Ann Thorc Surg, 2005

New technologies New technologies SummarySummary AF-B, video-endoscopy, EBUS and low-dose CT established techniques role still mostly under discussion Newer techniques on the way Newer therapy options on the way indications and limitations?