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      A new mode of ventilation for interventional pulmonology. A case with EBUS-TBNA and debulking

      case-report

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          Abstract

          Lung cancer is still underdiagnosed mainly due to lack of symptoms. Most patients are diagnosed in a late stage where unfortunately only systematic therapy can be applied. Fortunately in the last five years several novel therapies and combinations have emerged. However; in certain situations local therapeutics modalities have to be applied in order to solve emergency problems as in the case that we will present. Convex-EBUS probe was used along with a novel method of ventilation which keeps PCO 2 concentration satisfyingly low.

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          Central Airway Obstruction: Benign Strictures, Tracheobronchomalacia, and Malignancy-related Obstruction.

          Septimiu Murgu, Katarine von Lang Egressy, Balaji Laxmanan … (2016)
          The purpose of this article is to provide an update on methods for palliating symptoms in patients with histologically benign and malignant central airway obstruction. We review the published literature within the past decade on postintubation, posttracheostomy, and TB- and transplant-related airway strictures; tracheobronchomalacia; and malignant airway obstruction. We review terminology, classification systems, and parameters that impact treatment decisions. The focus is on how airway stent insertion fits into the best algorithm of care. Several case series and cohort studies demonstrate that airway stents improve dyspnea, lung function, and quality of life in patients with airway obstruction. Airway stenting, however, is associated with high rates of adverse events and should be used only when curative open surgical interventions are not feasible or are contraindicated.
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            Molecular Targeted Drugs and Biomarkers in NSCLC, the Evolving Role of Individualized Therapy

            Kalliopi Domvri, Paul Zarogoulidis, Kaid Darwiche … (2013)
            Lung cancer first line treatment has been directed from the non-specific cytotoxic doublet chemotherapy to the molecular targeted. The major limitation of the targeted therapies still remains the small number of patients positive to gene mutations. Furthermore, the differentiation between second line and maintenance therapy has not been fully clarified and differs in the clinical practice between cancer centers. The authors present a segregation between maintenance treatment and second line and present a possible definition for the term “maintenance” treatment. In addition, cancer cell evolution induces mutations and therefore either targeted therapies or non-specific chemotherapy drugs in many patients become ineffective. In the present work pathways such as epidermal growth factor, anaplastic lymphoma kinase, met proto-oncogene and PI3K are extensively presented and correlated with current chemotherapy treatment. Future, perspectives for targeted treatment are presented based on the current publications and ongoing clinical trials.
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              Cone Beam Computertomography (CBCT) in Interventional Chest Medicine - High Feasibility for Endobronchial Realtime Navigation

              Wolfgang Hohenforst-Schmidt, Paul Zarogoulidis, Thomas Vogl … (2014)
              Introduction: Currently there are several advanced guiding techniques for pathoanatomical diagnosis of incidental solitary pulmonary nodules (iSPN): Electromagnetic navigation (EMN) with or without endobronchial ultrasound (EBUS) with miniprobe, transthoracic ultrasound (TTUS) for needle approach to the pleural wall and adjacent lung and computed tomography (CT) -guidance for (seldom if ever used) endobronchial or (common) transthoracical approach. In several situations one technique is not enough for efficient diagnosis, therefore we investigated a new diagnostic technique of endobronchial guided biopsies by a Cone Beam Computertomography (CBCT) called DynaCT (SIEMENS AG Forchheim, Germany). Method and Material: In our study 33 incidental solitary pulmonary nodules (iSPNs) (28 malignant, 5 benign; mean diameter 25 +/-12mm, shortest distance to pleura 25+/-18mm) were eligible according to in- and exclusion criteria. Realtime and onsite navigation were performed according to our standard protocol.22 All iSPN were controlled with a second technique when necessary and clinical feasible in case of unspecific or unexpected histological result. In all cases common guidelines of treatment of different iSPNs were followed in a routine manner. Results: Overall navigational yield (ny) was 91% and diagnostic yield (dy) 70%, dy for all accomplished malignant cases (n=28) was 82%. In the subgroup analysis of the invisible iSPN (n=12, 11 malignant, 1 benign; mean diameter 15+/-3mm) we found an overall dy of 75%. For the first time we describe a significant difference in specifity of biopsy results in regards to the position of the forceps in the 3-dimensional volume (3DV) of the iSPN in the whole sample group. Comparing the specifity of biopsies of a 3D-uncentered but inside the outer one third of an iSPN-3DV with the specifity of biopsies of centered forceps position (meaning the inner two third of an iSPN-3DV) reveals a significant (p=0,0375 McNemar) difference for the size group (>1cm) of 0,9 for centered biopsies vs. 0,3 for uncentered biopsies. Therefore only 3D-centered biopsies should be relied on especially in case of a benign result. Conclusion:The diagnostic yield of DynaCT navigation guided transbronchial biopsies (TBB) only with forceps is at least up to twofold higher than conventional TBB for iSPNs <2cm. The diagnostic yield of DynaCT navigation guided forceps TBB in invisible SPNs is at least in the range of other navigation studies which were performed partly with multiple navigation tools and multiple instruments. For future diagnostic and therapeutic approaches it is so far the only onsite and realtime extrathoracic navigation approach (except for computed tomography (CT)-fluoroscopy) in the bronchoscopy suite which keeps the working channel open. The system purchase represents an important investment for hospitals but it is a multidisciplinary and multinavigational tool with possible access via bronchial airways, transthoracical or vascular approach at the same time and on the same table without the need for an expensive disposable instrument use.
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                Author and article information

                Contributors
                Paul Zarogoulidis
                Journal
                Journal ID (nlm-ta): Respir Med Case Rep
                Journal ID (iso-abbrev): Respir Med Case Rep
                Title: Respiratory Medicine Case Reports
                Publisher: Elsevier
                ISSN (Electronic): 2213-0071
                Publication date PMC-release: 28 November 2017
                Publication date Collection: 2018
                Publication date (Electronic): 28 November 2017
                Volume: 23
                Pages: 38-42
                Affiliations
                [a ]Pulmonary-Oncology Unit, “Theageneio” Cancer Hospital, Thessaloniki, Greece
                [b ]Department of Respiratory and Critical Care Medicine, Changhai Hospital, The Second Military Medical University, Shanghai, China
                [c ]Surgery Department, “Interbalkan” European Medical Center, Thessaloniki, Greece
                [d ]Interventional Pulmonary Department, “G. Papanikolaou” General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
                [e ]Division of Pulmonology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra Hospital, Athens, Greece
                [f ]Medical Clinic I, “Fuerth” Hospital, University of Erlangen, Fuerth, Germany
                [g ]Sana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, “Hof” Clinics, University of Erlangen, Hof, Germany
                Author notes
                [∗ ]Corresponding author. pzarog@ 123456hotmail.com
                Article
                Publisher ID: S2213-0071(17)30327-1
                DOI: 10.1016/j.rmcr.2017.11.006
                PMC ID: 5723371
                PubMed ID: 29234593
                SO-VID: f2a61868-72b2-4d32-afc6-75b4da21f85a
                Copyright © © 2017 Published by Elsevier Ltd.
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 10 October 2017
                Date revision received : 26 November 2017
                Date accepted : 27 November 2017
                Categories
                Subject: Case Report

                Keywords: lung cancer,interventional pulmonology,ventilation,ebus
                Data availability:
                Keywords: lung cancer, interventional pulmonology, ventilation, ebus

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