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Lung cancer is not only the most commonly diagnosed cancer worldwide, but it is still the leading cause for cancer-related death. The 5-year survival for lung cancer in Europe and in the USA is totally 16%. Therefore, a palliative therapy regimen is required to control the disease and reduce symptoms with the objective of enhancing quality of life of lung cancer patients. In addition to chemotherapy that is still one of the most important pillars in the treatment of advanced lung cancer, further interventional strategies can be offered to improve a patient’s quality of life. A locoregional tumour progression is frequently associated with malignant pleural effusion or pericardial effusion, central airway obstruction, tracheo-oesophageal fistula, severe haemoptysis or superior vena cava (SVC) syndrome threatening life and necessitating urgent palliation. Recurrent pleural effusion causing dyspnoea can be managed by pleurodesis, serial thoracocentesis or insertion of an indwelling catheter. Symptomatic malignant pericardial effusion often requires an urgent pericardiocentesis. Furthermore, surgical procedures, instillation of sclerosing agents or local chemotherapy should be considered in refractory pericardial effusion. The therapy regimen of central airway stenosis includes mechanical and thermic endoscopic procedures providing rapid relief of symptoms. To prevent recurrence of airway obstruction, the insertion of a stent or palliative brachytherapy provide re-establishment of the patency of obstructed airways. Haemoptysis can be managed by bronchoscopic interventions as well as by arterial embolization or palliative thoracic radiotherapy. The therapy of SVC syndrome is dependent of histology. In small-cell lung cancer, chemotherapy is recommended. In non-small-cell lung cancer, stent insertion and/or radiotherapy are the therapeutic pillars.

Although known for more than 80 years, ‘collateral ventilation' (CV) became a focus of endoscopic research in the recent decade. Implantation of one-way valves presents an effective treatment option for patients with advanced heterogeneous emphysema optimizing symptoms and quality of life. However, this treatment modality is only successful in case of low interlobar CV. Based on this evidence, attempts to develop different approaches for the quantification of CV have been initiated. In this regard, it is crucial to illuminate the meaning and different aspects of CV.

Background: Contrast-enhanced, computed tomography of the chest (angio-CT) is the preferred modality for evaluating central pulmonary embolism (PE). However, acute PE must be diagnosed quickly, and contraindications to contrast agents, hemodynamic instability preventing transport and radiation exposure may limit its use. Because the mediastinal vessels lie within 5 mm of the trachea and central airways, endobronchial ultrasound (EBUS) imaging may be a feasible alternative to detecting PE. Objectives: To demonstrate the feasibility of detecting PE in the central airways by EBUS. Methods: In a prospective, multicenter pilot study, consecutive patients underwent flexible bronchoscopy with a convex EBUS probe under local anesthesia and moderate sedation within 24 h after angio-CT had documented a central PE. The EBUS images were compared to the CT findings. Results: Among 32 patients (mean age 69 years, 20 men), angio-CT documented 101 PE, of which 97 (96%) were also detected with EBUS. The 4 emboli not detected consisted of 1 in a middle lobe and 3 in a left upper lobe artery. At least 1 embolus was detected with EBUS in every patient, which is sufficient to confirm a diagnosis of central PE. No bronchoscopic complications were observed. Mean procedure time was reduced from 5 min in the first 16 patients to 3 min in the last 16. Conclusions: In this pilot study, EBUS was a feasible and safe approach to detecting central pulmonary emboli. Blinded, comparative trials will be necessary to evaluate its use as a primary tool for diagnosing these emboli.

Background: The advent of endoscopic lung volume reduction (ELVR), especially relying on valve technology to achieve atelectasis, has aroused new interest in the assessment of collateral ventilation, which has been implicated in ELVR failures. We are reporting on the use of a catheter-based device that measures airway pressures and flows, and calculates airway resistance in vivo. Objectives: To assess the safety of this catheter-based system and the feasibility of obtaining measurements predictive of atelectasis after ELVR. Methods: Patients undergoing ELVR were prospectively included in this double-blind cohort study. Each lobe targeted for ELVR was blocked with a catheter system (Chartis® System; Pulmonx, Inc., Redwood, Calif., USA); pressures and flows were assessed continuously. The primary endpoints were to evaluate the safety and feasibility; the secondary endpoint was to assess whether there was a relationship between the measurements and the incidence of atelectasis following ELVR. Results: From June 2008 to November 2008, 25 patients were included in the study. All procedures could be performed without any complications. Due to pneumothorax in 1 case and inability to assess the catheter-based measurements in 4 cases, the final analysis included 20 patients. Atelectasis occurred in 8 out of 20 cases following implantation. In 18 patients (90%), the resistance measurements correlated with the postimplantation atelectasis visualized on a chest X-ray; in 2 patients (10%), a mismatch was detected. Conclusions: Resistance measurements were safely and successfully achieved. In 90% of the analyzable cases, the resistance measurements correlated with the occurrence of atelectasis after ELVR. The clinical impact of these findings will need to be evaluated in subsequent trials.

Valve implantation has evolved as a therapy for patients with advanced emphysema. Although it is a minimally invasive treatment, it is associated with complications, the most common being pneumothorax. Pneumothorax occurs due to the rapid target lobe volume reduction and may be a predictor of clinical benefit despite this complication. The objective of this study was to conduct an exploratory data analysis of patients who developed a pneumothorax following endoscopic valve therapy for emphysema. This study performed a retrospective evaluation of pneumothorax management and the impact of pneumothorax on clinical outcomes in 70 patients following valve therapy in 381 consecutive patients. Pneumothorax rate following valve therapy was 18%. Pneumothorax management consisted of chest tube insertion, valve removal, and surgical intervention in 87% (61/70), 44% (31/70), and 19% (13/70) of the patients, respectively. Despite pneumothorax, patients experienced modest but significant improvements in lung function parameters (forced expiratory volume in 1 second: 55±148 mL, residual volume: -390±964 mL, total lung capacity: -348±876; all <0.05). Persistent lobar atelectasis 3 months after recovering from pneumothorax, which was associated with relevant clinical improvement, was observed in only 21% (15/70) of the patients. Pneumothorax is a frequent severe complication following valve therapy that requires further intervention. Nevertheless, the pneumothorax does not impair the clinical status in the majority of patients. Patients with lobar atelectasis benefit after recovering from pneumothorax in terms of lung function parameters.

Background: In recent years experience has been accumulated in percutaneous radiofrequency ablation (RFA) of lung malignancies in nonsurgical patients. Objectives: In this study, we retrospectively evaluated a simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions. Methods: CT-guided transthoracic core needle biopsy of solitary pulmonary lesions suspicious for malignancy was performed and histology was proven based on immediate frozen sections. RFA probes were placed into the pulmonary tumors under CT guidance and the ablation was performed subsequently. The procedure-related morbidity was analyzed. Follow-up included a CT scan and pulmonary function parameters. Results: A total of 33 CT-guided biopsies and subsequent RFA within a single procedure were performed. Morbidity of CT-guided biopsy included pulmonary hemorrhage (24%) and a mild pneumothorax (12%) without need for further interventions. The RFA procedure was not aggravated by the previous biopsy. The rate of pneumothorax requiring chest tube following RFA was 21%. Local tumor control was achieved in 77% with a median follow-up of 12 months. The morbidity of the CT-guided biopsy had no statistical impact on the local recurrence rate. Conclusions: The simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions is a safe procedure. The potential of this combined approach is to avoid unnecessary therapies and to perform adequate therapies based on histology. Taking the local control rate into account, this approach should only be performed in those patients who are unable to undergo or who refuse surgery.

Background: Autofluorescense (AF) bronchoscopy is an established method to detect dysplasia and carcinoma in situ (CIS). Several different systems are currently available. Objectives: This study aimed to directly compare the LIFE system (Xillix Technologies, Vancouver, Canada) and the D-light system (Storz, Tuttlingen, Germany). Methods: In a prospective study performed between May 1999 and October 2000, we examined patients with risk factors for lung cancer that underwent bronchoscopy with both (LIFE and D-light) systems in a crossover design. The findings were classified into normal, abnormal and suspicious lesions by independent investigators and then compared. Results: This study comprised 332 patients (220 males, 112 females, mean age 62.7 years, range 40–85); 1,117 biopsies were studied (mean biopsy rate 3.4/patient). In 817 biopsies, mucosal areas were classified as normal with respect to control biopsy specimens, 113 as abnormal and 187 as suspicious using AF bronchoscopy. The histological examination showed normal tissue in 850 cases, in 55 cases scarring or inflammation, in 62 meta- or dysplasias, in 11 carcinomas in situ and in 127 invasive tumors. In only 5 cases, classifications were found to be different between the two systems (2 normal, 2 dysplasias, 1 invasive tumor). The mean time for the LIFE system examination amounted to 11.7 min (range 6.2–19.5) and for the D-light system to 7.4 min (range 4.3–11.9). This difference was statistically significant (p < 0.001). Conclusion: Both systems yielded comparable results. The examination time was significantly shorter with the D-light system, which may be explained by the more comfortable handling and the direct switch between white light and AF imaging. Different trials using either methodology could be compared directly.