Heinrich D. Becker

Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions

Transbronchial biopsy (TBBX) for peripheral lung lesions is usually performed with the help of fluoroscopy, but the yield varies widely. This feasibility study aimed to assess the ability of endobronchial ultrasound (EBUS) to provide imaging guidance for TBBX. In a prospective study, 50 consecutive patients referred for TBBX for peripheral lesions underwent fluoroscopy-guided and EBUS-guided TBBX in random order. Diagnostic yields were compared for both modalities and feasibility was assessed for EBUS. Diagnostic material was obtained in 80% of patients with EBUS and 76% of patients with fluoroscopy. There was a nonsignificant trend for EBUS to be better than fluoroscopy for lesions <3 cm in diameter. Four lesions could not be visualised with EBUS. There were no significant complications associated with the use of EBUS. Endobronchial ultrasound-guided transbronchial biopsy is feasible. It appears to be at least equivalent to fluoroscopy without the accompanying radiation exposure. Further large-scale studies are indicated to assess the possible role of endobronchial ultrasound as a potential imaging method of choice for the biopsy of peripheral lung lesions.

Electromagnetic Navigation during Flexible Bronchoscopy

Background: Flexible bronchoscopy is routinely utilized in the diagnosis and treatment of various lung diseases. Nondiagnostic bronchoscopy leads to more invasive interventions, such as transthoracic needle aspiration, mediastinoscopy or even thoracotomy. Electromagnetic navigation is a novel technology that facilitates approaching peripheral lung lesions, which are difficult to sample by conventional means. The navigation system involves creating an electromagnetic field around the chest and localizing an endoscopic tool using a microsensor overlaid upon previously acquired CT images. Objectives: To determine the practicality, accuracy and safety of real-time electromagnetic navigation, coupled with previously acquired 3D CT images, in locating artificially created peripheral lung lesions in a swine model. Methods: Peripheral lung lesions were created in four swine models by insertion of a metal tube (1 × 10 mm) via a transthoracic approach. An electromagnetic field was created by placing the animal on an electromagnetic location board. A position sensor incorporated into the distal tip of a dedicated tool was used to navigate to the various target lesions. Information gathered in real time during bronchoscopy was presented on a monitor simultaneously by displaying previously acquired CT images. Upon reaching the target lesion, biopsies were performed and the functionality and safety of the superDimension/Bronchus System was observed and documented. Results: The registration accuracy expressed by the fiducial target registration error, expressing both the registration quality and the stability of fiducial (registration) points, was 4.5 mm on average. No adverse effects, such as pneumothorax or internal bleeding, were encountered in any of the animals in this study. Conclusions: Real-time electromagnetic positioning technology coupled with previously acquired CT images is an accurate technology added to standard bronchoscopy to assist in reaching peripheral lung lesions and performing biopsies.

Endobronchial ultrasound in therapeutic bronchoscopy

Endobronchial ultrasound (EBUS) has been introduced as an adjunct to diagnostic bronchoscopy as it allows evaluation of the submucosal and parabronchial structures. Its use in therapeutic bronchoscopy has not been assessed. A large observational study of the value of EBUS in therapeutic bronchoscopy is presented here. From January 1998–January 2001 all patients undergoing therapeutic bronchoscopy and EBUS were evaluated prospectively. Patient demographics, indication for bronchoscopy, interventional treatments used and changes in therapy as influenced by the use of EBUS were documented. A total 2,446 therapeutic bronchoscopies were performed. In 1,174 cases EBUS was used (29% mechanical tumour debridement, 20% airway stenting, 13% Neodymium:yttrium aluminium garnet (Nd:YAG) laser use, 23% argon plasma coagulation, 11% brachytherapy, 2% foreign body removal and 2% endoscopic abscess drainage). EBUS guided or changed therapy significantly in 43% of cases. Changes included adjustment of stent dimensions, termination of tumour debridement when nearing vessels, and referral for surgical interventions rather than endoscopic treatment. Complications associated with EBUS use were minimal. No patient undergoing EBUS guided tumour destruction experienced severe bleeding or fistula formation. In summary, endobronchial ultrasound was easily performed and changed or guided therapeutic decisions during therapeutic bronchoscopic procedures in a substantial number of cases. As this may result in better outcomes, it has become a standard adjunct in the authors practice.

Autofluorescence Bronchoscopy – A Comparison of Two Systems (LIFE and D-Light)

Background: Autofluorescense (AF) bronchoscopy is an established method to detect dysplasia and carcinoma in situ (CIS). Several different systems are currently available. Objectives: This study aimed to directly compare the LIFE system (Xillix Technologies, Vancouver, Canada) and the D-light system (Storz, Tuttlingen, Germany). Methods: In a prospective study performed between May 1999 and October 2000, we examined patients with risk factors for lung cancer that underwent bronchoscopy with both (LIFE and D-light) systems in a crossover design. The findings were classified into normal, abnormal and suspicious lesions by independent investigators and then compared. Results: This study comprised 332 patients (220 males, 112 females, mean age 62.7 years, range 40–85); 1,117 biopsies were studied (mean biopsy rate 3.4/patient). In 817 biopsies, mucosal areas were classified as normal with respect to control biopsy specimens, 113 as abnormal and 187 as suspicious using AF bronchoscopy. The histological examination showed normal tissue in 850 cases, in 55 cases scarring or inflammation, in 62 meta- or dysplasias, in 11 carcinomas in situ and in 127 invasive tumors. In only 5 cases, classifications were found to be different between the two systems (2 normal, 2 dysplasias, 1 invasive tumor). The mean time for the LIFE system examination amounted to 11.7 min (range 6.2–19.5) and for the D-light system to 7.4 min (range 4.3–11.9). This difference was statistically significant (p < 0.001). Conclusion: Both systems yielded comparable results. The examination time was significantly shorter with the D-light system, which may be explained by the more comfortable handling and the direct switch between white light and AF imaging. Different trials using either methodology could be compared directly.

Endoscopic Drainage of Lung Abscesses: Technique and Outcome

BACKGROUND Lung abscesses commonly respond well to antibiotic therapy. In patients in whom conventional therapy fails, either percutaneous catheter drainage or surgical resection are usually considered, but are frequently problematic. This study describes our experience with endoscopic lung abscess drainage in patients in whom antibiotic therapy fails. METHODS Patients in whom antibiotic therapy for lung abscess (enlarging cavity or lack of improvement of clinical status) was unsuccessful were considered candidates if an airway connection to the cavity was present. Treatment decisions were made in a multidisciplinary chest conference. Pigtail catheters were placed via a guidewire approach into the cavities. The abscesses were flushed twice daily with gentamycin solution. If fungal infection was suspected, once-daily amphotericin B was added to the regimen. RESULTS Forty-two patients, from January 2000 to May 2002 (17 woman and 25 men) were included in this study (mean age, 48.9 years). Catheter placement was successful in 38 patients and led to successful therapy after a mean of 6.2 days of treatment (range, 3 to 21 days). Two patients required transient ventilation after catheter placement; there were no other complications. CONCLUSIONS Endoscopic lung abscess drainage in selected patients in whom antibiotic therapy fails is feasible and successful in experienced hands. This treatment represents an additional option for the chest physician other than percutaneous catheter drainage or surgical resection.

Electromagnetically navigated brachytherapy as a new treatment option for peripheral pulmonary tumors.

Purpose:This technical note describes the principles of navigated brachytherapy for treatment of peripheral non-small cell lung cancer (NSCLC).Material and Methods:In a prospective feasibility trial a first patient with medically inoperable NSCLC in the right upper lobe was treated with external-beam radiotherapy (50 Gy) and navigated endoluminal brachytherapy (15 Gy). Navigated bronchoscopy was performed with an electromagnetic navigation system for localization of a microsensor mounted on the tip of a dedicated catheter placed within the working channel of a bronchoscope. The probe can be actively guided by a steering mechanism to targeted lesions in the periphery of the lung. After successful localization of the NSCLC, endobronchial ultrasound (EBUS) was performed to confirm the exact position in the center of the lesion. A 6-F brachytherapy catheter was placed within the tumor. Primary 3-D-planned brachytherapy was performed on chest CTs acquired with the inserted catheter. High-dose-rate brachytherapy (370 GBq iridium-192) was applied as a boost three times a week (single dose 5 Gy) and provided highly conformal irradiations of the NSCLC including the draining bronchovascular bundle.Results:The brachytherapy catheter was tolerated well during treatment (5 days) and alimentation was possible without any problems. Repeated CTs showed stable positioning of the catheter. During follow-up (12 months), endoluminal ultrasound and CT demonstrated a partial remission while histology showed a complete remission of the tumor.Conclusion:Navigated brachytherapy for peripheral pulmonary tumors not amenable to conventional bronchoscopy is feasible.Ziel:Diese technische Mitteilung beschreibt die Grundlagen einer navigierten Brachytherapie zur Therapie von peripheren, nichtkleinzelligen Bronchialkarzinomen (NSCLC).Material und Methodik:Im Rahmen einer prospektiven Machbarkeitsstudie wurde ein Patient mit einem aus internistischen Gründen inoperablen NSCLC im rechten Oberlappen mit einer Teletherapie (50 Gy) und einer navigierten Brachytherapie behandelt (15 Gy). Die navigierte Bronchoskopie wurde mit einem elektromagnetischen Navigationssystem durchgeführt. Dieses System erlaubte eine Echtzeitdarstellung eines Mikrosensors, der an der Spitze eines speziellen Navigationskatheters angebracht und in den Arbeitskanal des Bronchoskops eingeschoben wurde. Der Navigationskatheter kann aktiv mit Hilfe eines Lenkungssystems zu peripheren Lungentumoren geführt werden. Nach erfolgreicher Ansteuerung des NSCLC wurde ein endobronchialer Ultraschall (EBUS) zur Bestätigung einer zentralen Positionierung im Tumor durchgeführt (Abbildungen 1 und 2). Im Anschluss wurde ein konventioneller 6-F-Bronchuskatheter im Tumor platziert. Auf der Basis eines Planungs-CT, das mit liegendem Brachytherapiekatheter gefahren wurde, erfolgte eine primäre 3-D-geplante Brachytherapie. Die High-Dose-Rate-Brachytherapy (370 GBq Iridium-192) wurde als Boostbestrahlung appliziert (3 × 5 Gy/Woche) und erlaubte eine hochkonformale Bestrahlung des peripheren NSCLC und des zuführenden bronchovaskulären Bündels (Abbildungen 3 und 4).Ergebnisse:Der Brachytherapiekatheter wurde während der Behandlung gut toleriert und erlaubte eine problemlose Ernährung des Patienten. Wiederholte CT-Untersuchungen zeigten eine stabile Lage des Katheters. In der Nachsorge (12 Monate) zeigten EBUS und CT eine partielle und die histologische Untersuchung eine komplette Remission des Tumors.Schlussfolgerung:Eine navigierte Brachytherapie zur Therapie peripherer NSCLCs, die nicht mit einer konventionellen Bronchoskopie erreicht werden können, ist durchführbar.

Recurrent respiratory papillomatosis: a rare chronic disease, difficult to treat, with potential to lung cancer transformation: apropos of two cases and a brief literature review.

Recurrent respiratory papillomatosis (RRP), which is caused exclusively by human papilloma virus (HPV), is a rare condition characterized by recurrent growth of benign papillomata in the respiratory tract. The papillomata can occur anywhere in the aerodigestive tract but most frequently in the larynx, affecting both children and adults. The management of this entity remains still challenging since no specific definitive treatment exists. Nevertheless, novel surgical interventions as well as several adjuvant therapies have shown promising results in the long-term palliative management of this debilitating disease. Despite its mostly benign nature, RRP may cause significant morbidity and mortality because of its unpredictable clinical course and especially its tendency, albeit infrequent, for malignant transformation. In this article, we present two patients with RRP; one underwent bronchoscopic laser ablation in combination with inhaled interferon-alpha administration that led to a long-term regression of the disease while the other patient was diagnosed with transformation to squamous cell lung carcinoma with fatal outcome. We include a review of the current literature with special emphasis on RRP management and the potential role of HPV in the development of lung cancer.

A new applicator, positionable to the center of tracheobronchial lumen for HDR-IR-192-afterloading of tracheobronchial tumors

A new bronchial applicator for afterloading irradiation is introduced which can be positioned to the center of the tracheobronchial lumen. The central position in the lumen leads to a clear improvement of dose distribution. The applicator is built on the principle of a coaxial tube. Parts of the outer cover can be expanded to baskets and effect a distance of the radiation source from the bronchial mucosa or tumor surface, and at the same time, expend a relief of extreme contact doses. No obstruction of the respiratory system through the positioning device will be caused. The positionable bronchial applicator seems to be suitable for reducing complications caused through high contact doses and irregular dose distributions and may be able to improve the results of endoluminal radiotherapy.

Effect and toxicity of endoluminal high-dose-rate (HDR) brachytherapy in centrally located tumors of the upper respiratory tract

Aim: To assess effect and toxicity of high-dose-rate afterloading (HDR) alone or in combination with external beam radiotherapy (EBRT) in centrally located tumors of the upper respiratory tract. Patients and Methods: From 1987 to 1996, 55 patients were treated. Twenty-one patients (group A1: 17 non-small-cell lung cancer [NSCLC], A2: 4 metastases from other malignancies) were treated using HDR alone due to a relapse after external beam irradiation. In 34 previously untreated and inoperable patients (group B1: 27 NSCLC, B2: 7 metastases from other malignancies) HDR was given as a boost after EBRT (30 to 60 Gy, median 50). HDR was carried out with a 192Ir source (370 GBq). The brachytherapy dose (group A: 5 to 27 Gy, median 20; B: 10 to 20 Gy, median 15) was prescribed to 1 cm distance from the source axis. A distanciable applicator was used in 39/55 patients. Results: In group A1, a response rate (CR, PR) of 53% (group B1: 77%) was reached. The median survival (Kaplan-Meier) was 5 months in group A1 (B1: 20 months). The 1-, 3- and 5-year local progression free survival rates (Kaplan-Meier) were 66% (15%), 52% (0%), and 37% (0%) in group B1 (group A1). Prognostic favorable factors in group B1 were a tumor diameter < 20 mm, the lack of radiological mediastinal involvement, a complete remission, and a Karnofsky performance status > 70. Grade-1 or 2 toxicity (RTOG/EORTC) occurred in 0% in group A and in 6% in group B. We observed no Grade-3 or 4 toxicity. Complications caused by persistent or progressive local disease occurred in 3 patients in group A (fatal hemorrhage, tracheomediastinal fistula, hemoptysis) and in 2 patients in group B (fatal hemorrhage, hemoptysis). Conclusions: HDR brachytherapy is an effective treatment with moderate side effects. In combination with external beam irradiation long-term remissions can be reached in one third of the patients.Ziel: Evaluierung von Effektivität und Toxizität der endoluminalen High-dose-rate-(HDR-)Brachytherapie als alleinige oder kombinierte (EBRT) Therapie bei zentral sitzenden Tumoren der oberen Atemwege. Patienten und Methode: Von 1987 bis 1996 wurden 55 Patienten behandelt. 21 Patienten (Gruppe A1: 17 Patienten mit nichtkleinzelligem Bronchialkarzinom [NSCLC], A2: vier Patienten mit Metastasen anderer Tumoren) wurden bei Lokalrezidiven nach vorheriger perkutaner Bestrahlung ausschließlich endoluminal bestrahlt. Bei 34 inoperablen und vorher unbehandelten Patienten (Gruppe B1: 27 NSCLC, B2: sieben Metastasen anderer Tumoren) wurde die Brachytheranie als Boost nach externer Bestrahlung (30 bis 60 Gy, Median 50) appliziert. Die endoluminale Bestrahlung wurde mit einer 192Ir-Quelle (370 GBq) durchgeführt. Dosiert wurde auf 1 cm Quellenabstand (Gruppe A: 5 bis 27 Gy, Median 20; B: 10 bis 20 Gy, Median 15). Ein distanzierbarer Spreizkorbapplikator wurde bei 39/55 Patienten verwendet. Ergebnisse: In Gruppe A1 wurde ein Therapieansprechen (CR, PR) in 53% erzielt (Gruppe B1: 77%). Das mediane Überleben (Kaplan-Meier) betrug fünf Monate in Gruppe A1 (B1: 20 Monate). Das lokalrezidivfreie Ein-, Drei- und Füf-Jahres-Überleben (Kaplan-Meier) betrug in Gruppe B1 ((A1) 66% (15%), 52% (0%) und 37% (0%). Als prognostisch günstige Faktoren konnten in Gruppe B1 ein Tumordurchmesser < 20 mm, radiologisch fehlende mediastinale Beteiligung, eine komplette Remission und ein Karnofsky-Index > 70 ermittelt werden. Grad-1- oder -2-Toxizität (RTOG/EORTC) trat in keinem Fall in Gruppe A und in 6% in Gruppe B auf. Wir beobachteten keine Grad-3- oder -4-Toxizität Tumorassoziierte Komplikationen kamen in drei Fällen in Gruppe A (Blutung, tracheomediastinale Fistelung, Hämoptysen) und in zwei Fällen in Gruppe B vor (Blutung, Hämoptysen). Schlußfolgerungen: Die endoluminale HDR-Brachytherapie ist eine effektive Therapie mit moderaten Nebenwirkungen. In Kombination mit externer Radiotherapie können Langzeitremissionen bei einem Drittel der Patienten erzielt werden.

Narrow Band Imaging Videobronchoscopy Improves Assessment of Lung Cancer Extension and Influences Therapeutic Strategy

OBJECTIVE Narrow band imaging (NBI) videobronchoscopy is a new technique aimed at lung cancer detection. This study investigated its sensitivity and specificity for evaluation of lung cancer extension and its possible influence on therapeutic decision, compared with white light videobronchoscopy. METHODS In this prospective study, we evaluated 106 patients with suspected lung cancer. All patients were examined using EVIS LUCERA videoendoscopy system. In every patient, at least three biopsies were taken from places visualized as pathologic, surrounding primary tumor, and three biopsies from places that appeared normal. The overall number of biopsies performed in 106 patients was 636. RESULTS The specificity and sensitivity of NBI in revealing greater lung cancer extension were 85.6% and 95%, respectively; positive and negative predictive values were 84% and 95.6%, respectively. Specificity and sensitivity were significantly better when compared with white light bronchoscopy alone (P < 0.01). NBI led to the change in therapeutic decision in 14 patients. There was statistically significant correlation between NBI assessment of tumor extension and change in therapeutic decision (P < 0.000). CONCLUSIONS NBI showed significantly better specificity and sensitivity in the assessment of lung cancer extension. NBI proved that it might have potential influence on therapeutic decision, making it more accurate. The procedure is safe and easily deployed in everyday practice.