By Helen K. Kelley
Pulmonology, an internal medicine subspecialty, is concerned with diseases of the lungs and bronchial tubes and often involves evaluation of the upper respiratory tract (nose, pharynx and throat) as well as the heart. Interventional pulmonology is a relatively new field in pulmonary medicine that uses endoscopy and other tools to diagnose and treat conditions in the lungs and chest.
Flexible bronchoscopy useful in diagnostics, therapeutic applications
“Fiber optic bronchoscopy did its part to change the world in late ’60s and early ’70s,” says William R. Kenny, M.D., of Piedmont Physicians Pulmonary of Atlanta. “The technology kept evolving, resulting in flexible bronchoscopes with ultrasound probes that can transmit data in real-time today. Now, we are able to see through the wall of the trachea or bronchus, which is especially helpful to examine and needle biopsy lymph nodes or masses that are suspicious for cancer or infection.”
This technique, called endobronchial ultrasound (EBUS), uses ultrasound along with bronchoscopy to visualize the airway wall and structures adjacent to it. It offers physicians a means of making more accurate diagnoses as well as performing therapeutic procedures in patients with certain lung diseases and conditions. According to Dr. Kenny, having this improved visualization can lead to a more accurate diagnosis and help determine the best course of treatment. It can also assist in more accurate staging of cancers.
“The electromagnetic navigation (ENB) procedure makes it possible to perform diagnostics on nodules in the lungs that were previously not accessible,” says Dr. Kenny. “The superDimension™ navigation system creates a 3-D CT scan of the nodule, plotting its exact location in the lung. Then, the system guides a steerable catheter that can biopsy a tumor distally in the lung. This is a big improvement over the use of interventional radiology, with less risk of pneumothorax.”
Dr. Kenny adds that flexible bronchoscopy is helpful in performing therapeutic applications via various instruments that can be passed through the bronchoscope.
“Most of the scopes have channels that can accommodate brushes and biopsy forceps, which obtain cytology and histology specimens,” he says. “We can also use scopes for procedures such as balloon dilation of a constricted bronchus, cauterization of a mass or loop cautery to remove a polyp, obtaining uncontaminated fluid samples, or removing a foreign body that the patient accidentally aspirated.”
The advancing technology continues to provide pulmonologists with enhanced capabilities.
“The scopes are getting better all the time,” Dr. Kenny says. “For example, today we have digitized images. Everything I’m looking at on the screen is a digital image that can be copied, printed or magnified. That’s an advantage.”
Interventional pulmonology plays important role in multidisciplinary approach
Interventional pulmonology (IP) is a discipline that involves the use of less invasive endoscopic procedures in the diagnosis and potential therapy of patients with malignant and non-malignant diseases involving the lung and the chest cavity.
According to Rabih Bechara, M.D., FCCP, Chief of Interventional Pulmonology, Pulmonary & Critical Care Medicine at Cancer Treatment Centers of America, because of its numerous applications, IP plays an important role in a multidisciplinary approach to treating patients with lung diseases.
“Patients have better outcomes when a team of physicians cares for them; importantly, each member of that team brings his or her special set of skills to the table,” says Dr. Bechara, who is also Professor of Medicine at Georgia Regents University School of Medicine. “For example, a patient with cancer may be receiving treatment from a radiation oncologist. Another team member, the interventional pulmonologist, can assist the radiation oncologist by placing markers in the patient’s tumor to help guide the delivery of radiation in a more accurate and safe manner.”
Interventional pulmonologists perform therapeutic procedures in patients with malignant or benign airway obstruction. In addition, they perform advanced endoscopic procedures that enable thoracic surgeons to localize small lung nodules prior to surgery. The latter results in less tissue loss during resection. Additionally, IP has taken on an increasingly important role in the staging of lung cancer, a crucial step in the management of patients with lung malignancies.
“Earlier diagnosis is always best, but appropriate staging is equally important in directing what type of therapy is needed,” says Dr. Bechara. “In the past, we relied on more traditional invasive surgical procedures to stage patients with nodes in the chest area. But today, endoscopic ultrasonography provides high specificity and sensitivity, is much less invasive and is very reliable in the staging process.”
Endoscopy can also prove helpful for cancer patients who have become resistant to their current treatment.
“We know that cancer cells sometimes mutate, therefore becoming resistant to treatment. So if a patient isn’t responding to therapy, something may have changed within their cancer cells,” Dr. Bechara says. “The latest endoscopic techniques allow the interventional pulmonologist to re-biopsy these patients in order to acquire new tissue, which can be examined to see if the cancer cells have mutated. Then, the multidisciplinary team can create a new treatment plan, tailored to the patient, based on the specific characteristics of his or her cancer cells.”
