O-026 Electromagnetic navigation bronchoscopy

Oral Sessions/Chest medicine~endoscopy and interventional bronchoscopy

$12

Methods: 135 patients with inoperable advanced stage lung who were palliated with non-covered SEMS. 23 (17%) had tumor re-growth noted either by surveillance bronchoscopy or CT scan imaging Endebrenchial tumor ablation of re~]rewth through the SEMS was attempted with PDT in 11 of the 23 pat]ants. Pat]ants rec.elved Photofrln® 2 m~'kg and were b'eated 46 hours later with 630nm of red light at a dose of 100 1,50 J/cm 2 from a diode laser lqssue response and SEMS integnty was documented visually and with biopsies by bronchoscopy at day 7. Light disthbution in,lye through SEMS was assessed in vlt]-o by a phantom model employing a HE NE laser collimated to a 11 mm beam and collected by a CCD camera after passing through a sample piece of a standard SEMS. Results: All 11 patients demonstrated uniform tumor ablat]on with a visual complete response (106% of stent visible and free of redundant tissue) by day 7. Visual examination of all stents revealed no displacement, fracture. deformity or occlusion Random biopsies from tissue adjacent or below metal failed to demonstTate viable tumor Phantom model data demonstrated light transmission with 18 to 22% attenuation in the presence of metal stents. however there were discrete areas ef amplified attenuation that coincided te the junction of two metal strands where they twist to a new direction An equivalent clinical attenuation was not observed Conclusions: Palliation for obstTucting airway lesions with stent placement is becoming common placed. Tumor regrowth through stents despite maximum chemotherapy and er radatien therapy has been reported te occur in 15-26% of patients. Treatment options for these pat]ants are limited given concerns of thermal damage to SEMS with laser. APC or elecb'ocautery and time issues with cryotherapy. PDT offers a rapid ablatrve technique with an i r ~ v e assessment demonstrating a complete clinical response and immunity era PDT effect to the actual metal. PDT should be considered as a safe and effective tumor ablation technique in patients with SEMS piacament

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Electromagnetic navigation bronchos¢opy

T Glides The Clave~and Clinic Foundat]on, Clave/and, USA

Background: Bronchoscopic yield for the clagnesis of lung cancer is vanable based on size and location of the lesion as well as operator expertise and type of sampling instTument Biopsies done without a visible endebrenchial lesion are done blindly. Penpheral lesion biopsies are often roughly guided by fluoroscopy. CT fluoroscopic guidance of bronchoscopy is net wldell available in most centers. The use of multiplanar CT planning has added to increased yield but even if a lesion has a dear bronchus leading into it. the bronehoscopic directed instruments may go astray dunng the procedure. The use of electremagnet]c navigation and real time muliplanar CT guided bronchoscopy have recently been shown to have yield of 69% in subjects with peripheral lesions in a pilot study The current study was designed to assess the "reachability" of peripheral lesions as well as mediastinal llmphnedes using standard bronchoscopy instTuments guided by the superDimensiorYBronchus ® system. Methods: An OpenJ_abel. Single Center. Feasibility Study te Demonstrate Ability to Reach Lung Targets (Peripheral Lung Lesions and Mediastinal Lymph Nodes) was approved by the local IRB The elecb'emagnetic navigation system or SDBS (sugerOimens~on/Brenchus system ®. superOimension Ltd.. Herzllla. Israel) is an imageguided localization tool that assists in plaong bronchoscopio biopsy instruments. CT scan of the chest saved on CE~Rom was downloaded into the SDBS software. Planning ocoJrred prior to the procedure with marking of 3 5 registration points and targets (meclastinal or hilar llmphoodas and/or peripheral lesions) The pnmary outcome of the study was the "reachability" of suspicious lesions Reachability is defined when any specimen obtained brenchoscopicalll was either diagnostic, suspicious or consitsted of lymphoid tissue in the case of TBNA of llmphnodas Flexible brenchoscopy was conducted in an outpatient bronchoscopy suite under local anesthesia and conscious sedation with an Olympus flexible videobronchoscope with 2 8ram working channel. Results: Thus far. 13 patients have granted consent and undergone diagnostic bronchoscopy wlth SDBS. Twelve penpheral lesions and 9 llmphnedes or mediastinal lesions were sampled. The perlpberal lesions were between 8rnm and 78ram. The mediastical lesions were between 20ram and 30ram. Six of 13 (46%) bronchoscopy procedures yielded a definitive diagnosis of cancer. Three additional procedures yielded borderline results. Borderline results were considered reachable when a biopsy yielded lymphoid cells, an alternative diagnosis or suspicious but nondiagnostic results Two of these three eventually led to defihltive diagnoses of adenocarcinoma (case 5) and sarcoidesis (case 10) Nine of thirteen (69%) of the bronehoscopies results were "reachable" Eight (8,8%) of the meclastinal neecle biopsies were "reachable" for either definitive tissue or benign lymphoid tissue Conclusion: The use of the SDBS during r e , h e brenchoscopy is associated with 69% reachable lesions. A dagnosis of cancer was made in 46% of all pat]ants. The SDBS system incorporates multiplaear CT planning. virtual bronchoscopy and a real time navigation system with an extendable working channel which makes most les~ons reachable during diagnostio flexible bronchoscopy.

Table 1. ,/Incicates which site was considered "reachable". Bordedine and clagnestic results were considered "reachable". Patient PL (mm)

LN (mm)

Result

1 2 3

~ (LUL: 2 0 x 2 2 x 1 9 ) .,/(LUL; 1 7 x 2 0 x 1 8 ) ~ (RUL; 7 6 x 6 8 x 7 3 )

Diagnostic Diagnostic Bordar4ine

4

.,/(RLL: 39 x 34 x 38) V' (RUL; Unknown) (RUL; 20 x 17 x 9) • • • (RLL; 6 x S x S ) (LLL: 6 x 6 x S ) (LUL; 1 5 x 2 4 x 1 4 )

.,/(AP window: 31 x 3 0 x 3 5 ) • • • ../(Rt para~rachea; 22x15x23) • • • .~ (AP wlndew; 2 3 x 2 6 x 2 5 ) • • • .~ (Rt Hilum: Unknown) (Rt. Hilum; 1 1 x 1 2 x 1 4 ) • • • ,/(Sub-canna: 2 0 x 2 0 x 1 3 ) , / ( R t Hilum: 2 5 x 1 4 x 1 3 ) • • • ,/(Su#carlna; 2 8 x 2 5 x 1 3 ) ,/(Sub-carina: 2 8 x 2 5 x 1 3 )

Nendiagnostic Bordedine

5 6 7 8 9 10 11 12 13

[0•

.,/(RLL: 2 0 x 2 0 x 1 4 ) ~/(RLL; 2 9 x 4 4 x 5 3 ) ~/0q~LIL:39x`51 x41)

Diagnestic Border4ine Nendiagnostic Diagnostic Nendiagnostic

Bordedine Diagnostic Diagnostic

Recent advances In endoscol~c eady detection of bronchial lesions

N. Ikada. H. Honda. A. Hayashi. M. Tsubei. J. Usuda. T. Ohira. K. MlyaJima. Y. Suga. ~ Hirane. H. Kate. Department at Thoracic Surge~ Tokyo Medical

Ur, verstty, Tokyo, Japan The key of early detection is viewed as a hall gral in the search for the development era powerful strategy to effectively t]-eat, and ult]matell eliminate the most lethal malignant dsease worldwide: lung cancer. Bronehoscopy is one of the representative modal~]as for early detection of lung cancer, and the last decade has witnessed several advances in both the technical and dinical aspects of bronchology, leading to better diagnostic and therapeutic yields The advances in technology produced new clinically beneficial developments, especially autofluorescanco bronehoscopy (AFB) AFB has become increasingly adopted since the early 1990's and several studies have shown that it improved the sensitivity of detection of cancerous and precancerous lesions of the airway, especially those in the intraepithelial stage We examined 600 lung cancer and high risk patients using AFB and showed that AFB is also useful in the objec0ve evaluation of the margin oftbe tumor before surgery or endoscopic treatment as well as in the localization of the lesions ef cases with abnormal sputum cytologyfincings. We have also employed the revolutionary AFB which was combined with vldeoendoscopy system. A total of 154 consecutive patients were stucled using this system. containing of 83 known or suspected lung cancer cases. 46 cases with abnormal sputum cytology findings. 10 follow up cases relieving lung cancer pperat]ons and 15 heavy smokers with respiratory symptoms. A total of 166 sites were biopsied to evaluate the relationship between endoscopic findings and pathology results The sensitivity of the system for CIS+dysplasia was 67% in white light and 92% in new AFB The newly-developped videoendoscopybased AFB system had sigrdficantll higher sensitivity for intTaepitbelial lesions than videoendescopy alone The prognostic implication of AF diagnosis is not yet dear However. most central type early stage cancers can be tTeated and successfully cured by endoscopic tTeatment such as photodynamic therapy Our diagnostic strategy for central type early stage lung cancer using AFB to evaluate the tumor extent as well as endoscopic ultrasonegrapby ([_BUS) and ppt]cal coherence tomograpby (OCT) for depth clagnos~s will be also dscussed.

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Rigid bronchoscoplc Intervention In patients wlth respiratory failure due to malignant central airway obstruction

H Kim. K Jean. C Yu. W Keh. G Suh. M Chung. O Kwon Sarnsung

Medical Center, Seoul, South Korea Background: Brenchescopic interventien in patients v~th malignant central airway obstruc~on provides the best ability te maintain airway contToI as well as initial stabilization of the airway, allowing the possibility of other effective therabeLrt]c modalibes such as surgery, r'aclation, or chemotherapy Methods: To describe advantage and limitation of emergency rigid bronchoscopic intervention, we reviewed the medical records el36 patients (26 males. median age 62 years, range 29 te 76 years) who underwent emergency airway intervention due to malignant central airway obstru~on Results: Impending respiratory failure could be succossfulll relieved in 34 out of 36 patients (94.4%). After airway was widened, addlt]enal definitive therapeutic modal~]as could be applied in 21 out ef 34 patients (61.8%). Longer survlval was observed in patients who underwent adclt]onal definitive therapy after bronchoscopic intervention (median 38.2 months, range 1.7 te