MSK Pioneers Interventional Pulmonology Techniques in Lung Cancer Field

Mohit Chawla, MD, FCCP

Director, Interventional Pulmonology

Robert P. Lee, MD

Co-Director, Complex Airway DiseasesDirector, Pleural Diseases

Nicholas Vander Els, MD, FCCP

Assistant Director, Interventional PulmonologyDirector, Pulmonary Function Laboratories

Memorial Sloan Kettering Cancer Center

New York, New York

Advanced interventional pulmonology (IP) techniques are revolutionizing the diagnosis and treatment of lung cancer. Minimally invasive bronchoscopy allows specialists to accurately diagnose and stage lung cancer and provide less-invasive therapeutic and palliative procedures for patients with malignant airway, pleural space, and lung parenchymal diseases.

At Memorial Sloan Kettering Cancer Center (MSK), we have been leading the field of IP since the inception of our IP Section with 2 attending physicians in 2008. Our team has pioneered new techniques and collaborated in the development of evidence-based clinical practice guidelines for symptom management in patients with lung cancer¹ ; the validation of an examination for doctors training in the field²; and, most recently, the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TNBA) for staging cancer.³

Minimally Invasive Procedures

Our IP experts collaborate with thoracic surgeons, interventional radiologists, radiation oncologists, and medical oncologists on the Thoracic Disease Management Team to develop the optimal diagnostic and treatment plan for each patient, often minimizing the need for multiple invasive procedures. We continue to develop and research new modalities, conduct clinical trials, and advance the field through our training fellowship and continuing medical education courses to train more subspecialists.Inserting instrumentation through a bronchoscope requires no incisions, providing patients with significant advantages compared with standard surgical or percutaneous options: less postoperative pain, faster recovery times, fewer complications, and shorter hospital stays. Many procedures are performed on an outpatient basis with low risk.

EBUS-TNBA involves using ultrasound waves to locate and biopsy lung masses and enlarged lymph nodes near tumors via needle aspiration. Navigational bronchoscopy combines data from CT scans with electromagnetic navigational instruments to identify, biopsy, and treat small peripheral lung lesions.

With therapeutic bronchoscopy, the bronchoscope serves as a conduit for inserting airway stents in patients with collapsed lungs or blocked airways, applying laser ablation to destroy tumor tissue, or treating airway defects.

Pleural space diseases are a common problem when cancer spreads to the chest. Using ultrasound guidance, we can insert indwelling tunneled pleural catheters, such as PleurX, that can be managed at home; perform pleurodesis to seal the pleural space to prevent further fluid accumulation; and drain fluid and remove scar tissue.

MSK-Impact Tumor Genetic Profiling Assay

IP procedures can relieve symptoms in patients with advanced lung cancers, in some cases allowing them to be taken off ventilators or improving their quality of life so that they can receive additional cancer treatment that may extend survival.A significant benefit of advanced diagnostic bronchoscopy is that the technique can be used to obtain biopsies of sufficient size for use with MSK-IMPACT™ (Integrated Mutation Profiling of Actionable Cancer Targets), MSK’s genetic-profiling assay that uses high-throughput next-generation sequencing to look for alterations in more than 465 cancer-associated genes and other molecular biomarkers.

IP Research

Developed by MSK’s Department of Pathology, the diagnostic test has been in use since 2014. With it we can rapidly assess a select range of solid tumor types, including lung cancer, and match patients with available targeted treatments or clinical trials for new agents wherever possible. The FDA recently approved MSK-IMPACT™.We continue to research different modalities and devices for the diagnosis and treatment of pulmonary disorders in patients with malignant diseases, patient outcomes after minimally invasive interventions, the role of oral microbiota in the development of pulmonary disease as a complication following hematologic stem cell transplantation, and other areas, all while minimizing risk and maximizing benefit. We recently reported data on the first-ever use of an absorbable gelatin and thrombin slurry for the bronchoscopic management of airway bleeding.

Radiotherapy is a highly effective treatment for lung cancer, but it can be challenging to deliver consistent therapy to tumor tissue when a patient breathes. MSK is among the first to conduct clinical trials to test the Calypso GPS system as a motion management tool for lung cancer radiation treatments. It has been used successfully for years to treat prostate cancer and is already approved by the FDA for this use. With the Calypso system, tiny beacons about 7.5 mm long are positioned in the lung near the tumor using minimally invasive bronchoscopy. The system triangulates the tumor’s location to ensure that radiation is precisely delivered to tumor tissue. If the patient breathes and the tracking field shifts, radiation is switched off, preventing damage to healthy tissue.

One study is investigating the Calypso system in combination with a deep inspirational breath hold. A second study is testing the system among patients who are not able to hold their breath, with the radiation switching on and off as they breathe normally.

Advancing the Field of IP

Finally, IP at MSK intends to be one of the first programs to implement the newest robotic technologies for bronchoscopy, which are currently under FDA review. This will greatly enhance our ability to localize lung tumors for diagnosis and, for the first time, reliably treat lung tumors bronchoscopically⁴ with thermal therapies, such as radiofrequency ablation or cryoablation.As a subspecialty, IP requires an extra year of training beyond traditional fellowships in both pulmonary medicine and critical care medicine. To train future leaders in the field, we established the first IP fellowship in New York. In June 2018, we will have graduated 4 IP fellows. Our IP graduates have all enjoyed success in progressive academic IP programs to which they have greatly contributed to their growth and advancement. In addition, 3 of our former pulmonary medicine fellows graduated from subsequent prestigious IP fellowships and all are leading highly successful academic IP programs throughout the country.

We also conduct an accredited annual continuing medical education course called Current Paradigms in Interventional Pulmonology: Endobronchial Ultrasound and Interventional Bronchoscopy, which provides practicing pulmonologists, intensivists, thoracic surgeons, nurses, and technicians with an advanced understanding of EBUS, interventional bronchoscopy, and cytological specimen processing.

IP remains a young field and is solidifying its foundation, to which MSK has provided substantial progress. There remains a great need for fully trained interventional pulmonologists throughout the country, especially in the era of improved utilization of small biopsies by cytopathologists and molecular pathologists (for diagnosis, staging, and molecular analysis), enhanced integration and acceptance of palliative care (in all cancers, but especially lung cancer),⁵ development of novel therapeutics (such as bronchoscopic ablation of peripheral lung tumors), and lung cancer screening.

References

1. Simoff MJ, Lally B, Slade MG, et al. Symptom management in patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(suppl 5):e455Se497S. doi: 10.1378/chest.12-2366.
2. Lee HJ, Feller-Kopman D, Shepherd RW, et al. Validation of an interventional pulmonary examination. Chest. 2013;143(6):1667-1670. doi: 10.1378/chest.12-1963.
3. Wahidi MM, Herth F, Yasufuku K, et al. Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration: CHEST guideline and expert panel report. Chest. 2016;149(3):816-835. doi: 10.1378/chest.15-1216.
4. Harris K, Puchalski J, Sterman D. Recent advances in bronchoscopic treatment of peripheral lung cancers. Chest. 2017;151(3):674-685. doi: 10.1016/j.chest.2016.05.025.
5. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi: 10.1056/ NEJMoa1000678.