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

2. 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

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

4. New technologies New technologies Rigid bronchoscopy

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8. 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

9. 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

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

11. 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

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

13. New technologies New technologies

14. New technologies New technologies EBB Diagnostic yield > 95 %

15. New technologies New technologies Adeno-Ca.Chondrohamartom Peripheral lesion

16. 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

17. New technologies New technologies TBB

18. New technologies New technologies TBB

19. New technologies New technologies yield of TBB 50-70 % (SPN 2-6 cm) Baaklini et al, Chest, 200064 % Gasparini et al., Chest, 199554 % Radke et al., Chest, 197964 % SPN < 3 cm Herth et al., Pneumologie, 2002 57 % Gacta et al., AJR, 198131% Shiner at al., Thorax, 198829 % Radke et al, Chest, 197940 %

20. 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 1995 107 48 42 20 570 37 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%

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

22. New technologies New technologies

23. 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

24. New technologies New technologies Autofluorescence

25. 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

26. New technologies New technologies StudyBiopsies (n) Preval. Dys/CIS (%) Sensitiv. WL (%) Sensitivity WL+AF (%) Relative Sensitivity Lam 1998700149566,3 Khanavkar 19981622734862,5 Vermylen 19991421125933,4 Venmans 2000790353841,6 Kusunoki 20002163964881,4 Shibuya 20012122168911,3 Sato 20011233285941,1 Häußinger ´053784458821,4 AF-System Published Data

27. 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

28. 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

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

30. New technologies New technologies 1mm Chip - technology

31. New technologies New technologies

32. 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

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

34. New technologies New technologies AFI

35. 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

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

37. 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

38. New technologies New technologies Endobronchial Ultrasound

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

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

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

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46. New technologies New technologies year N yield Krasnik et al.2003 35 92% Yasufuku et al.2003 17 89% Yasufuku et al.2004 67 91% Rintoul et al.2004 39 90% Herth et al.2005502 92% EBUS-TBNA-Scope

47. New technologies New technologies

48. New technologies New technologies EUS

49. New technologies New technologies EUS Authoryear N yield (%) Giovanni et al.1995 2283 Silvestri et al.1995 2789 Gress et al.1997 4395 Wiersma et al.199719292 Janssen et al.1998 3591 Rabe et al.1998 9580 Williams et al.1999 8290 Fritscher-R. et al.2000 3597 Wallace et al.200112187 Wiersma et al.2001 8696 Fritscher-R. et al2003 4193 Annema et al. 2003 1983

50. 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

51. New technologies New technologies Restaging Betticher et al., JCO, 2003 90 patients 3 cycles Cisplatin/Doxetacel Sugerbaker: ASCO Educational book, 1994

52. 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;42:311-18.

53. 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

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

55. 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

56. New technologies New technologies Electromagnetic Navigation SuperDimension™ Electromagnetic Navigation SuperDimension™

57. New technologies New technologies Electromagnetic Navigation SuperDimension™ Electromagnetic Navigation SuperDimension™

58. New technologies New technologies year N yield Schwarz et al.2003 17 89% Becker et al.2005 30 69% Stanzel et al.2005 10 72% Eberhardt et al.2006 20 70 % Electromagnetic navigation SuperDimension™ Electromagnetic navigation SuperDimension™ exam time  10-20 min Animal trial Feasibilty trial Lerning curve

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

60. New technologies New technologies

61. New technologies New technologies 3 cm patients (n) 21 29 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

62. 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

63. 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

64. New technologies New technologies Sideview Magnifying videoscope

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

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

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

68. New technologies New technologies Light Penetration Depth Narrow Band Imaging

69. 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

70. 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

71. New technologies New technologies 415nm465nm540nm

72. New technologies New technologies NBI Conventional

73. New technologies New technologies Narrow Band Imaging

74. New technologies New technologies Narrow Band Imaging

75. New technologies New technologies

76. 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

77. New technologies New technologies In vivo imaging of the scattering inherent in tissue Spatial resolution: 10 - 20μm, 10 times better than EUS Up to 2mm from the mucosal surface Non-contact index matching not required; without balloon filed with water

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

79. New technologies New technologies OCT

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

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

82. New technologies New technologies

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

84. 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

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

86. New technologies New technologies

87. New technologies New technologies NETT-trial

88. 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

89. New technologies New technologies

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

91. New technologies New technologies

92. 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

93. 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

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

95. 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?