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Bronchoscopic Procedures

Bronchoscopic Procedures. Asist.Prof.Dr.Sedat ALTIN Yedikule Chest Diseases Hospital. 250.000 out-patient in 2005 10.500 inpatient 2800 pts with lung cancer 5.000 bronchoscopy 250 endobronchial therapy 150 autoflouresence bronchoscopy 500 chemotherapy. Endobronchial therapy unit.

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Bronchoscopic Procedures

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  1. BronchoscopicProcedures Asist.Prof.Dr.Sedat ALTIN Yedikule Chest Diseases Hospital

  2. 250.000 out-patient in 2005 • 10.500 inpatient • 2800 pts with lung cancer • 5.000 bronchoscopy • 250 endobronchial therapy • 150 autoflouresence bronchoscopy • 500 chemotherapy

  3. Endobronchial therapy unit • All interventional procedures • Endobronchial Ultrasound • Superdimention • Autofluorescense bronchoscopy

  4. New Techniquesof Bronchoscopy • AF • Videobronchoscopy • Endobronchial ultrasound • Low-dose CT • Magnifying • NBI • Elektromagnetic navigation • Optical Coherence

  5. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Central Bronchogenic Carcinoma* Performance Characteristics of Different Modalities for Diagnosis

  6. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Peripheral Bronchogenic Carcinoma* *Performance Characteristics of Different Modalities for Diagnosis

  7. Sensitivity of Flexible Bronchoscopic Diagnosis of Bronchogenic Carcinoma by Size of Lesion*

  8. Stage 5-year-survival Dysplasie/CIS 95 % I 70 % II 35 % III A 20 % III B, IV 6 % All 8-13 % Kato et al., 1993

  9. PREINVASIVE LESIONS(WHO classification of lung tumours) Squamous Dysplasia (mild, moderate, severe) Carcinoma in situ (CIS) Atypical Adenomatous Hyperplasia (precursor of adenocarcinoma?) Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (precursor of tumourlets and typical or atypical carcinoid) Brambilla E et al, Eur Respir J 2000; 18: 1059)

  10. PREINVASIVE LESIONS(Natural history) MODERATE DYSPLASIA 11% SEVERE DYSPLASIA 19-46% INVASIVE CANCER CIS 22-56% All of the preinvasive lesions, including carcinoma in situ, are able to regress Bond et al. Cancer Detect Prev, 1986 Venmans et al. Chest, 2000

  11. FOLLOW-UP OF BRONCHIAL PRECANCEROUS LESIONS AND CARCINOMA IN SITU USING FLUORESCENCE BRONCHOSCOPY Bota S et al. Am J Respir Crit Care Med 2001; 164: 1688 416 bronchial intraepithelial lesions in 104 high-risk subjects, followed over a 2 yrs period Reserve cells hyperplasias and metaplasias: 37% regressed to normal 31.6% did not change 30% evolved to moderate dysplasia 2% progressed to a CIS Minor and moderate dysplasia 23% regressed to normal37% regressed to metaplasia 3.5% progressed to severe dysplasia37% stable High grade dysplasia 70% regressed to low grade lesion 19% persistent high grade 11% progressed to CIS CIS 16% regressed to nondysplastic status 6% regressed to moderate dysplasia 78% stable at 3 months

  12. EARLY DETECTION OF CENTRAL AIRWAYS LUNG CANCER MORPHOLOGIC CHANGES: normal epithelium 46 ± 3 microns dysplasia 70 ± 7 microns CIS 116 ±16 microns • Conventional white light bronchoscopy • dysplasia and CIS are difficult to detect (only a few cells thick: 0.2-1 mm; small surface diameter) • also experienced bronchoscopists detect only 29-40% of early lung cancers (Woolner LB et al. Atlas of Early Lung Cancer, 1993)

  13. Xillix New Life System Storz D-Light Pentax Safe 1000 Wolf Dafe EXCITATION LIGHT Incoherent light: Xenon light source (380-480 nm)

  14. AF-bronchoscopy

  15. European multicenter trial on diagnosis of early lung cancer by AFB* • 1173 smokers with additional risk of lung cancer • 2 randomised groups: • WLB alone • WLB plus AFB • Prevalence of moderate or severe dysplasia 2.1 fold in WLB/AFB group versus WLB (27 vs 13) • Prevalence of CIS 1.25 fold in WLB/AFB group versus WLB group (5 vs 4). *Hauinger K, Becker H, Stanzel F et allThorax, 60(6):496-503,2005

  16. D-LIGHT AUTOFLUORESCENCE IN THE DETECTION OF PREMLIGNANT AIRWAY CHANGES.A Multicenter TrialErnst A et al. Journal of Bronchology 2005; 12: 133 • Multicenter prospective, nonrandomized, self-controlled study (5 university-affiliated centers) • 300 patients (293 evaluated) • 821 biopsies • Sensitivity for premalignant lesions: • WL: 10.6% • AF: 61.2% • WL+AF 65.9% • Relative sensitivity: 5.78 • Specificity: • WL: 94.6% • AF: 75.3%

  17. EFFICIENCY FLUORESCENCE BRONCHOSCOPY ON FOLLOW-UP PATIENTS WITH OPERATED LUNG CANCERN Kalkan, G Günlüoğlu, S Altın, E Çetinkaya, N Şimşek Yedikule Göğüs Hastalıkları Hastanesi MS-017 9.Toraks Derneği Kongresi Formerly due to lung cancer operated 40 pts Metaplasie, mild displasie detection • Relative sensitivity: 2,94 Moderate and severe displasie, CIS • Relative sensitivity: 1,33

  18. AF-System Published Data

  19. AUTOFLUORESCENCE BRONCHOSCOPY: INDICATIONS • Screening for very high risk populationses. Uranium Miners (Horvath T et al. . Diagn Ther End 1999; 5: 91) • Abnormal sputum cytology / Crx negative for localization • Follow-up bronchoscopy in high risk patientsprevious surgery for lung or laryngeal cancer(Moro Sibilot D et al: Chest 2002; 122: 1902) • Pre-surgical evaluation of airways • determine margins of tumor (Sutedja TG et al: Chest 2001; 120: 1327) • assess bronchial tree for second primary • (incidence of synchronous rx occult lung cancer in patients with a first visible lung tumour: 7-14%) (Pierard P et al. Chest 2000; 117: 779)

  20. Autofluorescence BronchoscopyProblems/Side Effects • Prolonged examination time (~ 10´) • Decrease of specificity • Number of biopsies increasing • Possibility of complications • Costs • Problem of false positives • Inflammation, scar, former biopsy sites • True sensitivity? • Different systems • Lack of comparative studies

  21. Chip - technology 1mm

  22. Chipendoscopy vs. AF-Bronchoscopy EXERA BF – 160 (Olympus) vs. D-light (Storz) CIS Dys 3Dys 1+2 Meta EXERA2/(0,6%) 8/(2,7%)7/(2,3%) 1/(0,3%) AF2/(0,6%) 8/(2,7%)6/(1,9%) 5/(1,5%) 21 (7%) visible TU, all detected with both techniques Herth et al., Chest, 2004

  23. AFI

  24. Herth et al., Chest, 2005

  25. In our practice with AFB Starting middle of 2003 • Evaluation of endobronchial extent of the tumor at the preoperative staging • Synchron primer tm or preinvazive lesion detection at the preoperative staging • Synchron/metachron lesion detection of the postoperative follow-up patients • In the high risk population (20 pocket/year smoking history, follow-up patients operated for larynx Ca)

  26. Endobronchial Ultrasound

  27. Endobronchial UltrasoundIntroduction • Conventional bronchoscopy is limited to the lumen • Wall structure and parabronchial structures are important • Conventional imaging of airway structures is poor • Indirect signs • discoloration, swelling of mucosa • pathological vascularisation • distorsion

  28. Endobronchial UltrasoundTechnical Set-up • Flexible/ rigid bronchoscopy • EBUS processor • Balloon tipped catheters • Miniaturized 20 Mhz probe (2.8 mm channel) • Balloon/ catheter preparation • Balloon inflation

  29. Echoendoscopy (EBUS) • Recent technique • shows 5 to 7 echographic layers in the bronchial wall. • Gives an accurate view of the depth of invasion of an early stage cancer (correlation pathology / echo > 95 % (1,2). • 1- Kurimoto N. Chest 1999; 115:1500-1506 • 2-Miyazu Y. Am J Respir Crit Care Med 2002;165 :832-837.

  30. Endobronchial Ultrasound • Miniaturized probe

  31. Development of flexible introducer catheter with water filled ballon tip • 360° view to the paratracheal • and -bronchial structures • Depth of penetration up • to 5 cm • Water filled balloon surrounds the crystal • Ensures “coupling”

  32. Endobronchial UltrasoundAnatomy • Layered airway structure • Vascular structures • Masses, lymph nodes • Parenchymal disease • Key structures for orientation

  33. Lower trachea

  34. Right main bronchus

  35. Left main bronchus

  36. Endobronchial Ultrasound and IP Procedures • 1174 patients undergoing stents, laser, debridement etc were enrolled • EBUS changed therapy in 43% of cases • Changed stent sizes, ablation depth, endoscopy versus surgery • No fistulas or severe bleed since EBUS introduction • Eur Resp J 2002;20:118-21

  37. T-Staging

  38. Endoscopy

  39. EBUS

  40. Endobronchial Ultrasoundand Airway Walls • Airway tumor infiltration versus compression • 131 patients with central tumor on CXR • Underwent chest CT, EBUS, surgery when indicated • EBUS accurate >90% of cases, CT only 50% • Added minimal time and complication • May prevent unnecessary surgery • Chest 2003;123:463-7

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