Disclosures. Role of the Pulmonologist in a Multidisciplinary Thoracic Program. Introduction. Access. None. Access

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1 Role of the Pulmonologist in a Multidisciplinary Thoracic Program Disclosures None Ken Y. Yoneda, M.D. Professor of Medicine Division of Pulmonary and Critical Care University of California, Davis VA Northern California Health Care System Introduction Access Access Facilitation Innovation Present and available in clinic Present at Tumor Board Clinical expertise becomes focused on thoracic oncology Thoracic program becomes focused on the pulmonologist 1

2 Facilitation Evaluation of pulmonary nodules Diagnosis and staging lung cancer Evaluation and optimization of pulmonary function Evaluation and management of respiratory complications of thoracic malignancies Evaluating Pulmonary Nodules Determining probability of malignancy Evaluate patient characteristics of risk Evaluate pulmonary nodule characteristics Assess patient preference Determine course of action Observation and follow up Biopsy Surgery Diagnosing and Staging Lung Cancer Bronchoscopy Standard endobronchial or transbronchial biopsy w/ or w/o fluoroscopy Endobronchial ultrasound Electromagnetic navigation Virtual CT guided navigation: Broncus Lung Point Thoracentesis + pleural biopsy Evaluating and Optimizing Pulmonary Function Spirometry, lung volumes and diffusion capacity Restrictive disease pattern Obstructive disease pattern Mixed restrictive and obstructive pattern Exercise testing 2

3 Dyspnea Cough Evaluating and Managing Respiratory Complications of Thoracic Malignancies Pleural effusions Radiation pneumonitis Endobronchial tumor Bronchiectasis Bronchial stenosis Acute and chronic infections Innovation Endobronchial Ultrasound (EBUS) Electromagnetic Navigation Bronchoscopy CT Virtual Bronchoscopy Guided Navigation Endobronchial destruction of tumor Airway stenting EBUS Linear Convex Probe Ultrasound permanently attached to the distal end of a dedicated flexible bronchoscope Scans linearly, parallel to insertion direction Needle aspiration performed under real time ultrasound guidance Yasufuku J Thorac Oncol

4 Herth Eur Radiol Sheski Chest Yausufuku Gen Thorac Cardiovasc Surg 2008 EBUS-TBNA vs Mediastinoscopy Electromagnetic Navigation Bronchoscopy EBUS- TBNA Sensitivity Specificity False Negative 77.8% 87% 100% 100% 22% Accuracy 91.8% SuperDimension In Reach System Biopsy of peripheral nodules not visible by standard bronchoscopy (67-74% Sensitvity) Biopsy of mediastinal and hilar lymph nodes Cervical Med 83.3% 68% 100% 100% 41% 93.8% Yasufuku Proc Am Thorac Soc 2008 A553. Ernst J Thorac Oncol 2008 Eberhardt Chest Gildea Am J Respir Crit Care Med

5 SuperDimension In Reach System Virtual Navigation Virtual Bronchoscopy Guided Navigation Broncus Lung Point System Broncus Lung Point Image recognition program matches real-time bronchoscopy to CT virtual bronchoscopy Peripheral lung lesions Mediastinal and hilar lymph nodes Bascom R, Higgins W. Chest

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7 YAG laser Endobronchial Destruction of Tumor Argon plasma coagulation Cryoprobe Cryospray Cryospray Airway application of liquid nitrogen at -196 C Dispensed via a 7 french catheter through a standard bronchoscope Low pressure (2-3 psi) delivery of liquid nitrogen converted to a rapidly expanding gas Rapidly freezes and dessicates relatively large areas of tissue No damage to connective tissue or cartilage Re-epithelialization of airway mucosa Krimsky J Thorac Cardiovascular Surg Cryospray FDA approved for Barrett s esophagus but for use in the airway Small case series suggest it is safe and effective for relief of malignant airway obstruction Major complication in the airway is pneumothorax Abst: Krimsky. ATS Abst: Krimsky. World Lung Conference on Lung Cancer

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10 Airway Stenting Aero Covered Metal Stent Non expandable silicone Self expanding bare or partially covered metal stents Completely coated self expanding metal stents The only completely covered, self expanding metal stent with an FDA approved airway indication Combines structural integrity with prevention of tumor growth through the stent Fully removable Can be placed with direct bronchoscopic visualization of the distal (DV) or proximal deployment Can be placed under conscious sedation without fluoroscopic guidance 10

11 Aero UCSF/UC Davis Thoracic Oncology Conference The End 11