Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official world association for bronchology and interventional pulmonology expert panel consensus statement

Background: Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. Methods: A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. Results: Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. Conclusion: This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres

Interventional Bronchoscopy:State-of-the-Art Review

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases

Comprehensive Invasive and Noninvasive Approach to Diagnosis and Management of Non-small Cell Lung Cancer

In the United States, lung cancer is currently the leading cause of cancer mortality, with nearly 160,000 deaths estimated in 2014. Of newly diagnosed lung cancers, approximately 85% are non–small cell lung cancers (NSCLCs). Small cell lung cancer (SCLC) and NSCLC can often be distinguished based on clinical presentation and imaging findings. When SCLC is suspected, the diagnosis is typically established using noninvasive or minimally invasive means, and treatment is dictated by a dichotomous disease characterization: limited stage versus extensive stage disease

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146505/1/dc23975.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146505/2/dc23975_am.pd

The role of minimally invasive endoscopic techniques in the diagnosis, treatment and prevention of lung cancer

Squamous cell carcinoma of the lung arises from pre-invasive progenitors in the central airways. The archetypal model appears to be a stepwise morphological progression until there is invasion of the basement membrane. However, their natural history is not well understood and their treatment remains controversial, with radical therapies being offered to individuals who may never develop cancer. Autofluorescence bronchoscopy gives us the ability to follow the natural history of these lesions, with the prospect that early detection may improve survival. In this thesis, the natural history of pre-invasive disease is described in a prospective longitudinal cohort study. The data identifies a ‘high-risk’ cohort of patients with severe dysplasia and carcinoma in situ, in whom close surveillance detects multiple interval lung cancers at an early stage. The data from this indicates the need of a minimally invasive bronchoscopic treatment for these patients. A further prospective clinical trial evaluates the role of photodynamic therapy in individuals with early invasive carcinomas of the airway who were unfit for conventional lung cancer treatment. Photodynamic laser therapy (PDT) proved to be an effective therapy for patients with small and superficial lesions. However, PDT has not been tested in randomised controlled trials, so a randomised clinical trial (the PEARL trial) was designed to evaluate whether treating high-grade preinvasive lesions will avert progression into invasive carcinoma. Endoscopic laser resection of primary lung carcinoid tumours was also evaluated. This thesis demonstrates that laser can be used to effectively ablate carcinoid tumours. Treatment was particular effective in small intraluminal carcinoid tumours and may be an alternative to surgical resection. Finally, the role of sedation in interventional bronchoscopy was assessed in a prospective study for patients undergoing endobronchial ultrasound and transbronchial needle aspiration. This thesis demonstrates that endoscopist led sedation is comparable to anaesthetic led sedation, but identified the need for a randomised controlled trial

Diagnostics and treatment in bronchial carcinoid tumors

At the start of this thesis there were several unanswered questions with regard to optimal patient selection for different treatments of bronchial carcinoid. Also, there were unanswered questions with regard to classification of bronchial carcinoid on small histological samples and with regard to prognostic value of several new tissue biomarkers. The aim of this thesis was to further optimize patient selection for parenchyma sparing techniques, and to explore the potential value of biomarkers in the treatment of bronchial carcinoid. Part one (chapter 2-5) of this thesis describes the classification of bronchial carcinoid on small histological samples and the use of diagnostic and prognostic biomarkers. In Chapter 2 we analyze patient selection for endobronchial treatment and underscore the importance of radiological assessment of bronchial carcinoids. Differentiation between typical and atypical carcinoid according to the current WHO classification is accomplished by obtaining the mitotic count and the presence of necrosis. As outlined above, TC is defined as a neuroendocrine tumour with less than 2 mitoses per 2 mm2 and absence of necrosis, while AC is defined by 2-10 mitoses per 2 mm2 and/or the presence of (dot-like) necrosis. However, it is known that small biopsies have limited diagnostic value for the distinction between TC and AC. In Chapter 3 and Chapter 4 we analyzed biopsy-resection paired specimens of patients referred for treatment for bronchial carcinoid to measure accuracy of pretreatment biopsies and analyze the value of tumor biopsy size. Furthermore, we describe the reliability of different immunohistochemical markers on different biopsies and resection specimens, and assessed the impact of specimen size on the accuracy of the diagnosis. Because the current classification of TC and AC only partially reflects their metastatic potential, there is a need for more accurate prognostic biomarkers for bronchial carcinoids. In Chapter 5 we investigated a combination of morphological and novel immunohistochemical markers for predicting dissemination. Part two (chapter 6-8) focuses on therapeutic strategies and patient selection for EBT. In Chapter 6 we present the results of a systematic review of the available literature on the feasibility and outcome of endobronchial treatment compared to surgical resection. We studied several endpoints such as overall survival, disease free survival, recurrence rate, complications, quality of life, and healthcare costs. Where EBT can be curative for patients with small intraluminal carcinoid tumors, tumor debulking prior to surgery may potentially result in less lung parenchyma that has to be removed during surgery to achieve complete resection of the tumor. In addition, EBT may reduce the need for sleeve resection to achieve radical margins when bulky tumors are removed. It is in Chapter 7 that we investigated whether endobronchial therapy for bronchial carcinoid, if not curative, can reduce the extent of the surgical resection and whether EBT prior to surgery is associated with increased surgical morbidity. Several letters, in reply to comments from experts in the field of treatment for bronchial carcinoid tumors, regarding published studies by our group, are bundled in Chapter 8

Bronchoscopic needle aspiration in the diagnosis of mediastinal lymphadenopathy and staging of lung cancer

Transbronchial needle aspiration (TBNA) has the potential to allow adequate mediastinal staging of non-small cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy. Metastasis to the mediastinal lymph nodes is one of the most important factors in determining resectability and prognosis in non-small cell lung cancer. The importance of TBNA as a tool for diagnosing intrathoracic lymphadenopathy as well as in the staging of lung cancer has been reported in various studies. We performed a literature search in PubMed and Journal of Bronchology using the keyword transbronchial needle aspiration. TBNA is a safe and effective procedure to diagnose mediastinal lymphadenopathy. Real-time bronchoscopic ultrasound-guided TBNA is the new kid on the block, which can further enhance the sensitivity of bronchoscopy in the diagnosis of mediastinal lesions