Newtechnologies

Newtechnologies

FJF Herth

AFB, EBUS, EUS, HRCT, OCT,

or yet something else….

AFB, EBUS, EUS, HRCT, OCT,

or yet something else….

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Newtechnologies Thoraxklinik-HeidelbergThoraxklinik-Heidelberg

tuberculosis hospital 1895

since 1972 rebuild as clinic for lung diseases

320 beds / 3 departments

Thoracic surgery Oncology Pulmonology/Critical care med.

H. Dienemann P. Drings FJF Herth

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~ 5000 US/year

all interventional procedures

Endobronchial Ultrasound

Thoracoscoy

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Newtechnologies Rigid bronchoscopyRigid bronchoscopy

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Newtechnologies IS THIS THE IDEAL BRONCHOSCOPY SUITE?IS THIS THE IDEAL BRONCHOSCOPY SUITE?

ELECTROCAUTERYCRYOTHERAPY

BALOONS

MONITORS

BI-PLANE DIGITAL PULSE FLUORO

STENTS AUTOFLUORESCENCE

ENDOBRONCHIAL ULTRASOUND

ARGON PLASMA COAG

THORACOSOPYSUPERDIMENSION

EPACS

MONITORS

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BASIC SUITE

• Airway examination

• BAL

• Cytologic brushing

• Endobronchial Biopsy

• Transbronchial biopsy

• TBNA

ADVANCED SUITE

• EBUS

• Autofluorescence

• External Navigation

• Electrocautery / APC

• Cryotherapy

• PDT

• Laser

• Stenting

• Thoracoscopy

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Transbronchial needle

aspiration...

...TBNA for friends...What’s your

name?

S. Gasparini, Heidelberg, 2002

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• Schieppati, 1949

• Station 7 nodes

• Schiessle, 1962

• Mediastinal tumors

• Versteegh & Swierenga, 1969

• Determine inoperability for lung cancer

• Wang,1978

• Mediastinal LN staging

• Rigid

• Wang, Terry,1983

• Flexible techniqueSchieppati. Rev As Med Argent 1949;663:497

Schiessle. J Fr Med Chir Thor 1962;16:551Wersteegh, Acta Oto-laryng 1963;56:603

Wang et al., ARRD 1978;118:17Wang et al., ARRD 1983;127:344

TBNATBNA

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• TBNA needles

• 13 mm long

• 22 gauge

• 19 / 21 gauge

• Knowledge of node anatomical position

• Knowledge of technique

TBNATBNA

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Newtechnologies EBBEBB

Diagnostic yield > 95 %

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Adeno-Ca. Chondrohamartom

Peripheral lesionPeripheral lesion

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• Fluoroscopic guided TBBX routine

method for diagnostic of solitary

pulmonary nodules

• Disadvantages:

• Radiation load

• Yield depending from nodule-size

Peripheral lesionPeripheral lesion

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Newtechnologies TBBTBB

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Newtechnologies TBBTBB

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• yield of TBB 50-70 % (SPN 2-6 cm)

• Baaklini et al, Chest, 2000 64 %

• Gasparini et al., Chest, 1995 54 %

• Radke et al., Chest, 1979 64 %

• SPN < 3 cm

• Herth et al., Pneumologie, 2002 57 %

• Gacta et al., AJR, 1981 31%

• Shiner at al., Thorax, 1988 29 %

• Radke et al, Chest, 1979 40 %

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Author N. Patients Sampling instruments Sensitivity

Ellis1975

Cortese, Mc Dougall1979

Shure, Fedullo1983

Wang et al1984Gasparini et al1995

Katis et al1995

107

48

42

20

570

37

brushingbiopsybrushing + biopsybrushingbiopsybrushing + biopsybiopsytransbronchial needlebiopsy + needle + brushingbiopsy + brushing transbronchial needlebiopsytransbronchial needlebiopsy + needlewashingbiopsytransbronchial needlewashing+biopsy+needle

42%68%69%40%46%60%36%52%69%25%68%53%69%75%24%38%62%70%

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Technique and results

• AF

• Videobronchoscopy

• Endobronchial ultrasound

• Low-dose CT

• Magnifying

• NBI

• Optical Coherence

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• <5% of autofluorescence is from epithelium

• submucosa and cartilage autofluoresce strongly

• autofluorescence is a characteristic of the upper submucosa, due to depth of penetration of blue light

Qu et al. Optical Engineering 1995

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Newtechnologies AutofluorescenceAutofluorescence

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Newtechnologies AF-BronchsocopyAF-BronchsocopyAF-BronchsocopyAF-Bronchsocopy

Systems comparable

• Safe 100 – Xillix Pierrad et al, J Bronchol, 2001

• D-Light – Xillix Herth et al, Respiration, 2004

• Additional examination-time

• 4-7 minutes

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Study Biopsies(n)

Preval.Dys/CIS

(%)

Sensitiv.WL(%)

SensitivityWL+AF

(%)

Relative Sensitivity

Lam 1998 700 14 9 56 6,3

Khanavkar 1998 162 27 34 86 2,5

Vermylen 1999 142 11 25 93 3,4

Venmans 2000 790 3 53 84 1,6

Kusunoki 2000 216 39 64 88 1,4

Shibuya 2001 212 21 68 91 1,3

Sato 2001 123 32 85 94 1,1

Häußinger ´05 3784 4 58 82 1,4

AF-System Published DataAF-System Published Data

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Newtechnologies AF Bronchoscopy ConsiderationsAF Bronchoscopy Considerations

Points of discussion

• risk estimation

• numbers of the individuals studied

• expertise of the bronchoscopist

• consistency of pathologist‘s reports

• numbers ob biopies taken

Sutedja et al., Respiration 2003

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Newtechnologies Arguments against AFBArguments against AFB

• useful only in squamous cell (≤30%)

• „natural history“ unclear

• Goldstandard ?

• reduction of mortality?

• cost-effectiveness

• rating in workflow of screening ?

Mehta AC et al., J Bronchol 2003

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Newtechnologies Management of Early Lung Cancer

Evidence-based Clinical GuidelineManagement of Early Lung CancerEvidence-based Clinical Guideline

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1mm1mm

Chip - technologyChip - technology

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CIS Dys 3 Dys 1+2 Meta

EXERA 2/(0,6%) 8/(2,7%) 7/(2,3%) 1/(0,3%)

AF 2/(0,6%) 8/(2,7%) 6/(1,9%) 5/(1,5%)

21 (7%) visible TU, all detected with both techniques

Chipendoscopy vs. AF-BronchoscopyEXERA BF – 160 (Olympus) vs. D-light (Storz)

Herth et al., Chest, 2004

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Chhajed et al., Eur Respir J, 2005

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Newtechnologies AFIAFI

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EXERA D-light AFI

Visible Tu 9/9 8/9 9/9

CIS 1/1 1/1 1/1

Severe dysplasia 4/4 4/4 4/4

Moderate dysplasia 2/2 1/2 2/2

Mild dysplasia 4/5 2/5 5/5

metaplasia 1/5 0/5 4/5

Herth et al., Chest, 2005

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Breuer at al. Cancer Clin Res 2005

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• New techniques allows better detection

• Will the identification and treatment of early lung

cancer improve the overall mortality from lung

cancer ?

• “How we should treat?”

questionsquestions

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Newtechnologies Endobronchial UltrasoundEndobronchial Ultrasound

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early3.tifearly3.tif

Miazyu et al., AJRCCM, 2002

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Miyazu Y et al., Am J Respir Crit Care Med, 2002Miyazu Y et al., Am J Respir Crit Care Med, 2002

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Ultrasoundcontrolledpuncture

7,5-10 MHz

linear-scanner

EBUS-TBNA-ScopeEBUS-TBNA-Scope

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year N yield

Krasnik et al. 2003 35 92%

Yasufuku et al. 2003 17 89%

Yasufuku et al. 2004 67 91%

Rintoul et al. 2004 39 90%

Herth et al. 2005 502 92%

EBUS-TBNA-ScopeEBUS-TBNA-Scope

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Author year N yield (%)Giovanni et al. 1995 22 83Silvestri et al. 1995 27 89Gress et al. 1997 43 95Wiersma et al. 1997 192 92Janssen et al. 1998 35 91Rabe et al. 1998 95 80Williams et al. 1999 82 90Fritscher-R. et al. 2000 35 97Wallace et al. 2001 121 87Wiersma et al. 2001 86 96Fritscher-R. et al 2003 41 93Annema et al. 2003 19 83

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Diagnostic values of EUS-FNA for cancer in the mediastinum (Patients selected by CT)

• 22 studies with a total number of 1245 patients

• Sensitivity 0.61–1.00 (median 0.90)

• Specificity of 0.71– 1.00

EUSEUS

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Newtechnologies RestagingRestaging

Betticher et al., JCO, 2003

90 patients3 cyclesCisplatin/Doxetacel

Sugerbaker: ASCO Educational book, 1994

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Newtechnologies EUS-FNA after induction chemotherapyEUS-FNA after induction chemotherapy

• 19 patients with N-2 disease who had been treated with induction chemotherapy

Sensitivity specificity

EUS-FNA 75% 100%

Conclusion: EUS-FNA accurate method for restaging of mediastinal lymph nodes after induction therapy in NSCLC

Annema et al., Lung Cancer 2003;42:311-18.

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NewtechnologiesEBUS-TBNA after induction chemotherapyEBUS-TBNA after induction chemotherapy

• 83 patients with N-2 disease who had been treated with induction chemotherapy

Sensitivity specificity

EBUS-TBNA

70% 100%

Conclusion: EUS-FNA accurate method for restaging of mediastinal lymph nodes after induction therapy in NSCLC

Herth et al., ATS 2006, submitted

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Newtechnologies Coin lesionsCoin lesions

……. <2cm diameter. <2cm diameter

remains a diagnostic dilemmaremains a diagnostic dilemma

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Newtechnologies CT Roadmap is PreparedCT Roadmap is Prepared

Same Registration Points on CT and body are marked as coordinates

System marries CT images to patient’s body

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Newtechnologies Electromagnetic Navigation

SuperDimension™Electromagnetic Navigation

SuperDimension™

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Newtechnologies Electromagnetic Navigation

SuperDimension™Electromagnetic Navigation

SuperDimension™

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year N yield

Schwarz et al. 2003 17 89%

Becker et al. 2005 30 69%

Stanzel et al. 2005 10 72%

Eberhardt et al.2006 20 70 %

Electromagnetic navigationSuperDimension™

Electromagnetic navigationSuperDimension™

exam time 10-20 min

Animal trial

Feasibilty trial

Feasibilty trial

Lerning curve

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Newtechnologies EBUS guided TBBEBUS guided TBB

Tumor

1

1, 3 : no image

2

3

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< 3 cm > 3 cm

patients (n) 21 29 EBUS n, (%) 17 (80%) 23 (79%) Fluorosc n, (%) 12 (57%) 26 (89%)

n.s.p < 0,001

Herth et al., Eur Respir J, 2002

EBUS guided TBBEBUS guided TBB

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• 54 patients, diameter 2,2 cm• lesions visible with EBUS 48 (89%)• definitive diagnosis 38 (70%)

• NSCLC 29• TBC 3• Sarcoidosis 2• Harmatoma 2• SCLC 2

• undiagnosed SPNs• NSCLC 10• inflammatory 6

ResultsResults

Herth et al., Chest, 2006

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Newtechnologies ResultsResults

• Nodule-size: 2,2 cm (R 1,4-3,3)

• Numbers of biopsies 4,5 (R 3-6)

• Mean examination time (incl. biopsies):

• 12,3 min (6-18)

• 1 pneumothorax

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Sideview

Magnifying videoscopeMagnifying videoscope

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Video image (far sight)

Video image (near sight) Magnified video image

Fiberscope image

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Video Bronchscope Magnifying video bronchscope

Comparison of video imagesComparison of video images

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Shibuya et al., Thorax, 2003

Vasculary pattern

allows distinction

bronchitis /dysplasia

Magnifying video bronchoscopeMagnifying video bronchoscope

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Light Penetration Depth

Narrow Band ImagingNarrow Band Imaging

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It is expected that the correlation of the images between RGB channels will be decrease, and the tissue structure with Z axes will be more clearly reproduce as the color information.

Broad band filters

Narrow band filters

Narrow Band ImagingNarrow Band Imaging

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415nm 465nm 540nm

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NBI Conventional

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Newtechnologies Narrow Band ImagingNarrow Band Imaging

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Newtechnologies Narrow Band ImagingNarrow Band Imaging

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• broadband near-infrared light source

• emitted light splitted into sample and

reference beam

• reflected beams were recombined

• interference pattern is produced

OCTOCT

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• In vivo imaging of the scattering inherent in tissue

• Spatial resolution: 10 - 20μm, 10 times better than EUS

• Up to 2mm from the mucosal surface

• Non-contact index matching not required; without balloon filed with water

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0.75 mm

L

MMSubMME

0.75 mmL

MMSubM ME

C M

OCTOCT

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Newtechnologies OCTOCT

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Hanna et al., J Thorac Cardiovasc Surg, 2005

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• technique not available

• still ex vivo technique

• two papers colon cancer

• one lung paper published

OCTOCT

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Data courtesy of Dr. Inoue, Tokyo

Normal mucosaNormal mucosa

carcinomacarcinoma

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• prototypes for colonoscopy available

• first trial shows promising results

• early cancer sensitifity 97 %, specifity 99%

Limitation

• necessity of fluorescent dyes

• secretion (image quality)

• orientation

µ-Cosmµ-Cosm

Kiesslich et al., Gastroenterology, 2004

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Light Guide Light Guide Microscope Microscope

Observation of cilia movementObservation of cilia movement

10 ～ 20 ゜ 20 ～ 30 ゜

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Newtechnologies NETT-trialNETT-trial

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Newtechnologies basicsbasics

• Blocks inspiratory flow to diseased lung regions

• Reduces hyperinflation

• Re-directs airflow to healthier lung areas

• Improved breathing mechanics

• Physiologic and clinical improvement

Potential benefits of LVRS, but with a minimally invasive & potentially reversible

approach

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Emphasys™ Spiration™ Pulmonix™

Watanabe Spigots™ Exhale™

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Newtechnologies Endo - ValvesEndo - Valves

Self-expanding retainer- stabilizes device in airway

Flexible seals- conform to bronchial wall- prevent air leak around valve

One-way valve- blocks inspiration- allows mucus clearance

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Emphasys®

• 4 feasibility trials• VENT trial closed

Spiration®

• feasibility trial during ERSPulmonix®

• feasibility trial ongoingSpigots

• feasibilty trial ongoingBronchus

• feasibilty trial stpped

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6 MWT (meters)

Mean ±SE ±SD

Pre-op 1 Month 3 Months150

200

250

300

350

400

450

500

p= 0.002

FEV 1 (Liters)

Mean ±SE ±SD

Pre-op 1 Month 3 Months0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

p= 0.02

O2 Support (L/min)

Mean ±SE ±SD

Pre-op 1 Month 3 Months-1,0

-0,5

0,0

0,5

1,0

1,5

2,0

2,5

p= 0,006

ITGV

Mean ±SE ±SD

Pre-op 1 Month 3 Months4,4

4,6

4,8

5,0

5,2

5,4

5,6

5,8

6,0

6,2

6,4

6,6

6,8

7,0

7,2

p= ns

Venuta et al., Ann Thorc Surg, 2005

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Newtechnologies SummarySummarySummarySummary

• AF-B, video-endoscopy, EBUS and low-dose

CT established techniques

• role still mostly under discussion

• Newer techniques on the way

• Newer therapy options on the way

• indications and limitations?