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Interventional Pulmonology: Potentials, limits & QoL

Interventional Pulmonology: Potentials, limits & QoL. tg.sutedja@vumc.nl. Ethical: “being in accordance with the accepted principles that govern the conduct of a profession” Utility: “the quality or condition of being useful”. Palliative and curative approach. ACCP Lung Cancer Guidelines (1).

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Interventional Pulmonology: Potentials, limits & QoL

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  1. Interventional Pulmonology:Potentials, limits & QoL tg.sutedja@vumc.nl

  2. Ethical: “being in accordance with the accepted principles that govern the conduct of a profession” Utility: “the quality or condition of being useful”

  3. Palliative and curative approach

  4. ACCP Lung Cancer Guidelines (1) ACCP guidelines (1) • At every stage, patients and their relatives should be offered clear, full and prompt information in both verbal and written form • Patient preferences should take precedence over the views of relatives, and caregivers should be involved in decision making when patients wish

  5. ACCP Guidelines (2) • Toxitiy of palliative interventions must be weighed against benefits, and choice of treatment discussed with individual patient • Treatment should be directed towards extending life rather than prolonging death, towards reducing suffering both physical and spiritual, towards achieving acceptance rather than denial or delusion

  6. Friday afternoon’s case • Old lady, living alone, no relatives, heavy smoker, referred by GP, clinical end-stage (malignancy?), severe stridor SaO2 60%, imminent death due to respiratory failure, major airways obstruction • No advanced directives, was impossible to communicate • Your bronchoscopy team is against intervention. “There is too much risk, let her die”

  7. Questions: Q1: You are responsible (not team): YES NO Q2: You treat her: YES NO

  8. Liberalism vs. individualism

  9. Proxy, Euthanasia & Forbid to treat declarations

  10. Case 2: images

  11. Case 2: images

  12. Follow-up  “Dutch” reality • Rigid + biopsy and stenting (Noppen technique)  immediate relief • Monday diagnosis: >st. IIIB NSCLC  “I do not want to live any longer nor accept any proposal for further therapy” • Euthanasia request - granted (Dutch law!) (Wednesday) • Pathologist at post-mortem (Thursday): “Tom, your stent is perfectly positioned” • Good QoL of the patient, bad QoL of the team

  13. Chest 2001;120:1811-1814

  14. The et al. BMJ 2000;321:1376

  15. cutting edge vs. double edged sword • “Endoscopic phototherapy with a hematoporphyrin derivative has been describedas an alternative to surgical resectionin carefully selected patients”

  16. Preservation of QoL: smokers’ health with poor cardio-vascular-respiratory fitness balanced against Technical advancements: diagnostics and therapeutics becoming increasingly non- and minimally invasive and succesful

  17. Staging:Chest 2001; 120:1327, Clin Can Res 2005;111:6186 T 2-3 mm PET+ but N0!   Superficial intraluminal N0, visible borders by AFB

  18. Argon plasma + electrocautery, cryotherapy, [Nd-YAG laser, PDT, HDR brachytherapy]

  19. Argon Plasma Coagulation for occult cancer

  20. A case of occult cancer • 54-yrs old >40 pack years - slight hemoptysis referred Feb. 2000: severe dysplasia on brush cytology • Regular follow-up 4-monthly with HRCT and AFB • Aug. 2004: repeat AFB UDB suspicious; distal margin invisible at least severe dysplasia; brush cytology suspicious for malignant cells

  21. Left upper division bronchus

  22. Questions: Q3: 1. Follow-up 2. Intraluminal treatment 3. Intraluminal then surgery 4. Surgical resection

  23. Clinical decision and treatment • Distal microinvasion cannot be ruled out→ argon plasma coagulation followed by radical left upper lobectomy and SND • Resected specimen: squamous metaplastic field, no residual CIS, N0 stage!

  24. Questions: Q4: This case shows: 1. Local treatment is effective 2. Early intervention saves life 3. Screening & early intervention justifiable

  25. MDCT: multidetector CT (64 bits) VERY sensitive but very LOW positive predictive value

  26. PET negative lesion (Q5) 75 years-old previous laryngeal ca. & RU lobectomy, subsequent SPN left upper lobe →cytology negative → at highest risk for a third primary! • Treatment (resection/stereotactic RT)?: YES vs. NO

  27. PET negative 3rd primary (Q 6) Lobectomy upper lobe N0 BAC Noguchi type A →died of resp failure, treatment is however justifiable? YES or NO ?

  28. PET negative 3rd primary lesion Lobectomy upperlobe N0 BAC A →resp failuredied! How likely will this BAC A become the cause of death? Why not a “delayed” intervention?

  29. Lepidic (benign) ↔ hilic (malignant) “Benign” → local treatment Biology malignant thus nodal & distant mets

  30. Randomized: stage shift?Gohagan et al. Lung Cancer 2005; 47:9-15

  31. No stage shift: 5-year prospective LDCT; 1,118 individuals 3,356 NCNs;  17 stage I; mean Ø 14.4 mmSwensen et al. Radiology 2005; 235: 259 Conclusions: “CT allows detection of early-stage lung cancers. Benign nodule detection rate is high. Results suggestno stage shift”

  32. Cure rate increasemay equalthecohort biologically benign lesions! “under diagnosis” is mortal Cure rate↑without treatment “benign” cancer ↓ baseline shift equals overdiagnosis rate?

  33. Pathology review MLP Cancer 2002; 95:2361 • 3 pathologists “blinded” (Colby, Tazelaar, Travis) • Slides: 105/167 Mayo (366 total) •  stats: type tumor 0.65; invasiveness 0.67-0.84 • 77 screened vs 28 control: • 7 CIS all in the screened • 7 preinvasive in the screened vs one in control • Proportional CIS + pre-invasive 13/77=16.8%!

  34. Potentials, limits & QoL:1. The odds against science ( guidelines!)2. Medicine-bronchoscopy is culture ( (f)laws!)3. Interventional pulmonology is a fashionable science within a cultural contextEverything can be done, should it be done?

  35. The pride of Holland

  36. Survive with competitive risks Died at 114 years with stomach cancer at post-mortem

  37. How early?

  38. Overdiagnosis vs. Calvinistic perception If early treatment of (lung cancer or) any disease is successful, additional disease (human suffering) is: 1. Due to successful treatment that allow you to live 2. Despite successful treatment as disease is not always mortal

  39. Last question You have only enough money to pay one insurance premium every year and have therefore to choose: 1. pay health care insurance 2. pay death coverage and funeral insurance

  40. Questions: The more science knows, the bigger are the profits of insurance companies

  41. QoL and stage shift?

  42. www.bronchoscopy.org

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