Christophe Hermant

Integration of interventional bronchoscopy in the management of lung cancer

Tracheal or bronchial proximal stenoses occur as complications in 20–30% of lung cancers, resulting in a dramatic alteration in quality of life and poor prognosis. Bronchoscopic management of these obstructions is based on what are known as “thermal” techniques for intraluminal stenosis and/or placement of tracheal or bronchial prostheses for extrinsic compressions, leading to rapid symptom palliation in the vast majority of patients. This invasive treatment should only be used in cases of symptomatic obstructions and in the presence of viable bronchial tree and downstream parenchyma. This review aims to clarify 1) the available methods for assessing the characteristics of stenoses before treatment, 2) the various techniques available including their preferred indications, outcomes and complications, and 3) the integration of interventional bronchoscopy in the multidisciplinary management of proximal bronchial cancers and its synergistic effects with the other specific treatments (surgery, radiotherapy or chemotherapy). Central airway obstruction is a severe complication of lung cancer that can be managed by interventional bronchoscopy http://ow.ly/OdAhF

Techniques of endoscopic airway tumor treatment

Interventional bronchoscopy has a predominant role in the management of both early and advanced-stage airway tumors. Given the very poor prognosis of lung cancer, there is a need for new tools to improve early detection and bronchoscopic treatment of endo-bronchial precancerous lesions. In more advanced stages, interventional bronchoscopy plays an important role, as nearly a third of lung cancers lead to proximal airway obstruction. This will cause great discomfort or even life-threatening symptoms related to local extension, such as dyspnea, post-obstructive pneumonia, and hemoptysis. Surgery for very locally advanced disease is only effective for a limited number of patients and the effects of conventional antitumor therapies, like radiation therapy or chemotherapy, are inconstant and are too delayed in a palliative context. In this review, we aim to provide pulmonologists with an exhaustive technical overview of (I) the bronchoscopic management of benign endobronchial lesions; (II) the bronchoscopic management of malignant tumors, including the curative treatment of localized lesions and palliative management of malignant proximal airway stenosis; and (III) descriptions of the emerging endoscopic techniques used to treat peripheral lung tumors.

Endobronchial Metastases from Melanoma: A Survival Analysis.

Metastatic spread to the tracheobronchial tree from other than bronchopulmonary tumors is a common clinical problem. However, malignant melanoma, a highly metastatic potential tumor, is rarely metastasing in the airways. Therefore little is known about survival of patients with endobronchial metastasis from melanoma.

Stenting of Complex Malignant Central-Airway Obstruction Guided by a Three-Dimensional Printed Model Of The Airways

Conversion of anatomic images into physical objects using three-dimensional printing (3DP) is changing the way surgeons anticipate selected technical challenges. We report herein a case of malignant central airway obstruction in the right main bronchus. Because stenting of the primary right carina is difficult, as it depends on many diameters and distance measurements, we used 3DP to plan and guide the procedure. After virtual resolution of the extrinsic compression, a three-dimensional printed model of the airways helped us choose the model and dimensions of the stent, and allowed us to modify its accuracy before insertion.

Integration of 3D printing and additive manufacturing in the interventional pulmonologist's toolbox

New 3D technologies are rapidly entering into the surgical landscape, including in interventional pulmonology. The transition of 2D restricted data into a physical model of pathological airways by three-dimensional printing (3DP) allows rapid prototyping and fabrication of complex and patient-specific shapes and can thus help the physician to plan and guide complex procedures. Furthermore, computer-assisted designed (CAD) patient-specific devices have already helped surgeons overcome several therapeutic impasses and are likely to rapidly cover a wider range of situations. We report herein with a special focus on our clinical experience: i) how additive manufacturing is progressively integrated into the management of complex central airways diseases; ii) the appealing future directions of these new technologies, including the potential of the emerging technique of bioprinting; iii) the main pitfalls that could delay its introduction into routine care.

Assessing the feasibility of confocal laser endomicroscopy in solitary pulmonary nodules for different part of the lungs, using either 0.6 or 1.4 mm probes

Background Malignant solitary pulmonary nodules (SPN) have become more prevalent, with upper lobes predilection. Probe-based confocal laser endomicroscopy (pCLE) provides in-vivo imaging of SPN. However, the stiffness of the 1mm confocal probe (AlveoFlex) causes difficult accessibility to the upper lobes. A thinner 600μm probe designed for bile duct exploration (CholangioFlex) has the potential to reach the upper lobes. Objectives To examine the accessibility of malignant SPNs in all segments of the lungs using either the 0.6mm or 1.4 mm probe and to assess the quality and inter observer interpretation of SPN confocal imaging obtained from either miniprobes. Methods Radial(r)-EBUS was used to locate and sample the SPN. In-vivo pCLE analysis of the SPN was performed using either CholangioFlex (apical and posterior segments of the upper lobes) or AlveoFlex (other segments) introduced into the guide sheath before sampling. pCLE features were compared between the two probes. Results Fourty-eight patients with malignant SPN were included (NCT01931579). The diagnostic accuracy for lung cancer using r-EBUS coupled with pCLE imaging was 79.2%. All the SPNs were successfully explored with either one of the probes (19 and 29 subjects for CholangioFlex and AlveoFlex, respectively). A specific solid pattern in the SPN was found in 30 pCLE explorations. Comparison between the two probes found no differences in the axial fibers thickness, cell size and specific solid pattern in the nodules. Extra-alveolar microvessel size appeared larger using CholangioFlex suggesting less compression effect. The kappa test for interobserver agreement for the identification of solid pattern was 0.74 (p = 0.001). Conclusion This study demonstrates that pCLE imaging of SPNs is achievable in all segments of both lungs using either the 0.6mm or 1.4mm miniprobe.

Tracheal Glomangioleiomyoma Treated by Multimodal Interventional Bronchoscopy

Glomus tumors of the trachea are particularly rare, and their management is usually based on sleeve resection with end-to-end anastomosis. Glomangiomyoma represents the rarest histologic subtype and has been observed only once in the trachea. We describe the first case of tracheal glomangiomyoma treated by multimodal interventional bronchoscopy.

Bronchoscopic Multimodal Management of Tracheal Neurofibroma.

Neurofibromas involving airways are rare and their management is usually surgical. Herein, we report the case of an endotracheal polypoid neurofibroma successfully treated by multimodal interventional bronchoscopy and cryotherapy.

Efficacy of total lung lavage in pulmonary alveolar proteinosis: A multicenter international study of GELF

BACKGROUND: Total Lung Lavage (TLL) is considered as standard of care in Pulmonary Alveolar Proteinosis (PAP). Yet, new therapies have emerged in the treatment of PAP and therefore there is a real need to evaluate the efficacy of TTL in this rare disease. OBJECTIVES: The aim of this study was to assess the efficacy of TTL in patients with PAP. METHODS : We have included 33 patients who underwent TTL from 11 centers, members of the French-Speaking Endoscopy Group (GELF) for analysis. Data collection concerned patient9s and disease characteristics, pulmonary function tests (PFTs) before and after the procedure, and technical informations on the procedure. RESULTS: Patients with respiratory insufficiancy at presentation were 22 (68.75%). All patients underwent lung lavage by general anesthesia and selective lung ventilation, except one who underwent flexible bronchoscopy. We noted differences in the technique as 12 (36.36%) patients had percussion during the procedure and only 7(21.2%) underwent two-lungs lavage during one anesthesia. A median of 16.8 L were used to performed TLL (1.0L to 40L). Complications occured in 11 (33.3%) patients and 18(56.25%) of them relapsed in a median period of 16.9 months. No significant changes were found in all PFTs parameters studied, in exception to PaO2 which was after the procedure higher of 6.375 mmHg (p=0.0213 ; [95%CI: 1.03-11.7]) in comparison to before. CONCLUSION: Although the technique of TLL has a variability in its application, due probably to patient9s condition, it improves significantly patients9 short-term respiratory condition, by improving PaO2. However, long-term effect needs to be confirmed, as many of our patients relapsed.