Category Archives: Bronchoscopy

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: Conclusion

The classical study of Auerbach et al already has shown that early-stage lesions may contain malignant cells that are only several layers thick. Patient No. 20 had only a small intraluminal cancer on the segmental bifurcation and is currently without recurrence 38 months after extensive biopsy alone.
There are no nonsurgical procedures by which it is possible to detect accurately the extension of the ROLC into the bronchial wall; only HRCT scanning can indirectly give some information on this important issue. Whether endobronchial ultrasonography will improve our ability to assess tumor infiltration beneath the mucosa remains to be seen. Although endobronchial ultrasonography is clearly more sensitive than HRCT scanning for local staging of the bronchial wall, its impact on treatment strategy and outcome still has to be established.

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: AFB

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: AFBThe most important application of AFB (LIFE system [Laser Induced Fluorescence Endoscope]; Xillix; Vancouver, Canada) has been the early detection of preneoplastic lesions in the bronchial tree in high-risk patients. Data from previous studies- showed that using AFB resulted in the detection of significantly more preneoplastic lesions. Another possible useful application is the more appropriate sampling of tissue for histologic investigation resulting in less sampling error. In this study, we describe a possible new application of AFB as part of the staging procedure for patients with ROLC, especially to delineate the tumor margins compared to what is seen during WLB procedures. Furthermore, it is possible to control the extent of the target area during IBT session by using, for example, electrocautery. Staging inaccuracy may lead to late tumor recurrences and delays in making the better choice of treatment. In carefully selected patients, the curative potential of PDT, brachyther-apy, and electrocautery has been established.2-4Д2 Electrocautery during AFB is possible, and the change of autofluorescence color from red-brown to white-green can be seen easily (Table 1). Treatment efficacy may be improved by using AFB to assure the exact spot of the tumor and to enable the radical treatment of tumor margins.

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: Discussion

Both electrocautery and extensive biopsy obtained long-term complete responses (Table 1). All patients except one have been shown to be free of disease after a follow-up period of 30 to 50 months. One patient died because of very severe emphysema, but no recurrence was found 6 months prior to her death. One patient showed carcinoma in situ as a recurrence after electrocautery treatment, and RT then was administered because AFB showed that the tumor gradually had extended beyond the 1-cm2 limit.

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: Results

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: ResultsWhen HRCT showed bronchial wall thickening, peribronchial tumor infiltration, or enlarged lymph nodes, patients were considered to have locally advanced cancers (group A), and these patients were treated accordingly by chemotherapy, surgery, radiotherapy, or a combination of these.
Occult tumors detected by HRCT but with distal margins invisible on AFB were classified as not true early-stage cancers (group B). Immediate surgery was performed when the results of mediastinoscopy were negative (stage N0). If a patient was considered to have an inoperable condition due to, for instance, severe COPD or previous resection(s), IBT was performed and an extra margin of at least 1 cm distal of the tumor border was included in the target area during intraluminal treatment. For tumors located on the bifurcations of the segmental bronchi, external irradiation was given because of the relatively inaccurate dosimetry of PDT and brachytherapy in this situation. External radiation therapy (RT) does not include the mediastinum. Intraluminal tumors < 1 cm2, with visible distal margins and without wall thickening, peribronchial extension, or lymph node enlargement on HRCT were classified as true early-stage cancers that were suitable for IBT with curative intent (group C). AFB was used to assist treatment by delineating the tumor margins more accurately. Four monthly follow-up visits included AFB with biopsies, cytology brush biopsies, and HRCT scans, especially in patients with cancers that were still technically operable. Patient demographics and the findings of HRCT scans and AFB procedures are shown in Table 1.

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy: Materials and Methods

From the results of a number of studies, it has become clear that the size of the involved area is an important determinant for success. However, even for very experienced bronchoscopists, it remains difficult to delineate the margins of ROLC in the involved bronchial mucosa, especially when the tumor may extend beyond the visible part intraluminally. For preneoplastic lesions in the central airways, autofluorescence bronchoscopy (AFB) has been shown to increase the detection rate compared to the use of conventional white-light bronchoscopy (WLB) alone. Central and proximal airway branches can be inspected with the fiberoptic bronchoscope during WLB, and the additional use of AFB may help to delineate tumor margins more precisely.

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic Strategy

Autofluorescence Bronchoscopy Improves Staging of Radiographically Occult Lung Cancer and Has an Impact on Therapeutic StrategyOf all prognostic factors for non-small cell lung cancer, the most important one by far is the size of the primary tumor. This implies that, despite an overall disappointing low cure rate of only 13%, efforts to detect and treat lung cancer at the earliest stage are rewarded and will result in a much better outcome. The early detection of radiographically occult lung cancer (ROLC) is difficult, but at that stage it has the best prognosis, even among patients with early-stage cancers. One of the advantages of ROLC is the current availability of several therapeutic modalities, even in patients with severe COPD or cardiac problems, or after undergoing pulmonary resections. Treatment with curative intent is possi-ble. Reduced physical fitness may deem patients to have inoperable conditions, such that intraluminal bronchoscopic therapy (IBT) may be considered as an alternative for surgical resection. Intraluminal therapy such as photodynamic therapy (PDT) and electrocautery have been reported to be potentially curative for ROLC.

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (12)

We do appreciate that the number of endoscopic examinations, the type of endobronchial procedures (laser, TBNA, etc), and the training of our pulmonary fellows impacted on our repair cost. However, review disclosed that approximately 87 percent of our repairs were preventable, including perforation of the working channel, damage related to laser therapy, accidentally pinching the body of the FFB while closing the carrying case lid, or the patient biting on the fiberoptic bronchoscope.

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (11)

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (11)Following gas sterilization the ETO cap must be removed to reseal the FFB to ensure water-tightness. During gas sterilization maximally tolerated conditions are as follows: temperature of 55°C (131°F), pressure of 1.7 kg/cm2 (24 PSI), time of four hours, humidity of 50 percent, and gas concentration of 10 percent. with the insertion tube as straight as possible and the angulation control lock released. The storage location should be clean and dry with a constant temperature and good ventilation. The original carrying case should be used for shipping only. For shipping, the insertion tube should be coiled loosely with care taken not to damage the instrument during closure of the case lid. The ETO venting cap must be put on during longdistance transportation of the instrument. flovent inhaler

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (10)

Cleaning and Maintenance
Strict adherence to the recommended procedures for cleaning, disinfection, and sterilization must be employed as these instruments have limited tolerance for trauma, heat, and chemical agents. Care must be taken to immerse only appropriate parts in the cleaning solution. The proximal control unit, eye piece, or light connector of nonsubmersible FFBs should never be immersed in the cleaning solutions. For disinfection, use of the recommended agents for the suggested contact time will decrease the premature aging of components. Alkaline glutaraldehyde products (such as Cidex, Sonacide, Glutarex, and Sporicidin) are commonly used agents. When povidone-iodine (Be-tadine) is used the distal viewing tip should be thoroughly wiped to prevent yellowish discoloration of the viewing lens. The FFB should not be autoclaved or placed in boiling water. buy levaquin online

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (9)

Maintenance and Repair of the Flexible Fiberoptic Bronchoscope (9)Radiation
Fluoroscopy has added immensely to the procedure of fiberoptic bronchoscopy, especially while performing brushings, transbronchial biopsies, transbronchial needle aspiration of peripheral nodules,* and localized bronchography. Excessive exposure of the FFB to radiation may result in yellowish discoloration and darkening of both the fiber bundles and the visual image. The exact dose of radiation at which damage occurs is unknown and therefore unnecessary radiation should be limited. Specifically, the FFB should not be stored in areas where fluoroscopy is performed or roentgenograms are routinely taken.

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