But one of the mics just to make sure they all right exposures. So, um what is interventional pulmonology? This is a mind map which shows all the procedures that we do in a cancer center. We're just gonna be concentrating mainly on diagnosis of cancer and also palliative debulking and treatment of pleural disease. To break that down, we do a lot of airway procedures. So upper airway subglottic stenosis tracheostomy, clearance of tumor from the airways diagnosis and staging of lymph nodes. Bronchoscopy has evolved a lot over the last 200 years. Um Really the main iterations were uh rigid bronchoscopy in the late 18 hundreds. Um flexible bronchoscopy in the 19 sixties, what I call augmented bronchoscopy, which is the addition of endobronchial ultrasound and navigation and then finally robotic bronchoscopy in 28 brid bronco bronchoscopy is something we still use today. This is how it was practiced in the late 18 hundreds and this is how we do it today in a very similar fashion. This is a 71 year old with a history of Melanoma who presented with Wheezing. You can see a pedunculated tumor in the airway which was easily cleared with electrocautery, snare and ablation. Uh This patient un un underwent uh chemo immunotherapy and had an excellent outcome. Types of central airway obstruction can be intraluminal ex extrinsic compression or mixed. Sometimes you see there with uh infiltration of the submucosa uh with extrinsic compression or clearly a tumor blocking the airway and they're treated very differently. Uh This is a pedunculated carcinoid tumor that was removed by rigid bronchoscopy. You see that the mucosa beneath is fairly normal, the rigid is very useful in sort of scooping these tumors out protecting the contralateral airway, providing good clearance of large bulky tumors. Sometimes tumors have a very flat base, they cover bilateral airways and need to be managed very differently. This is a patient with a metastatic cancer involving the main Corina and both main stems with clearance of tumor. You can reduce breathlessness, keep people out of the hospital and on treatment. Sometimes when you clear a tumor which is just a simple endobronchial lesion, you get recurrence, that recurrence can be then mixed. So you get some extrinsic compression which even when you clear the exophytic tumor, there's persistent stenosis. This is when we employ stents, this is a silicon stent. These have been around since the 19 seventies and eighties. We still use exactly the same type silicones are easy to place very stable, they're inert and they provide good relief to our patients with shortness of breath. Sometimes we'll use metal stents. These are combined night alls or nickel titanium alloy with a um silicon coding. This is the patient who just blew through their immunotherapy. You see on the top of the screen, they had um recurrent hemoptysis which we perform cautery. Then they returned with a larger sub subcarinal mass. Then the subcarinal mass took over, put in one stent in the right lung. It then became even further obstructed, put in a total of I think five stents to keep these airways open. This patient ended up changing therapy. The nice thing about lung cancer if we can relieve breathlessness, give the our oncologist time to find the right therapy for them. This patient entered a clinical trial, their tumor melted away, ended up taking all five stents out. They've been disease free for two years. Sometimes we do. Hi, this is, this is a um thyroid cancer. You see, it's almost completely obstructing the trachea. When the person presented, they had extreme shortness of breath and dyspnea. This is almost complete obstruction of their high trachea. Put in a stent just to try and protect this airway as best we can. Once the stent is in, like I said, it buys our oncologist and radiation oncologist time. This is an anaplastic thyroid cancer. Very, very aggressive, fast moving, but now that the airway is protected, um the patient was able to be discharged and was actually started on an oral chemotherapy. Um They came in with extreme strider and then went home, uh safe with the treatment plan in place. Um Also sometimes patients come in with, with chronic issues. This is a patient with metastatic breast cancer. She had malaise shortness of breath cough, just really wasn't feeling well been on treatment for a long time, had known metastatic disease. But when we went in the airway was completely obstructed. This is the left main stem and right main stem really narrowed. My, my goal wasn't to reinflate the entire lung. Um It was really to see if she had developed a post obstructive pneumonia. So we go in and we dilate the airway, get Frank puss back, put in a stent and let it decompress. This patient just had a chronic infection that was really, really ruining her quality of life just by allowing that to decompress and let the antibiotics work. She again was able to stay out of the hospital and on treatment, she maintained a very good quality of life, was able to make all of her appointments and, and did very well after this. Now, a lot of what we do these days is diagnose new malignancies in the age of immunotherapy. A lot of the central airway obstruction can be, can be treated um and have good response with outpatient chemotherapies and immunotherapies, but with finding new malignancies, um the question is, how do we get them diagnosed in stage as quickly and safely as possible? We began doing robotic bronchoscopy in 2018 and this procedure really has three main parts. There's, there's navigation or driving out to the target, there's targeting and sampling. And then sort of the fourth part is adequacy. Do you have enough tissue for molecular testing with navigation? You're using AAA CT scan that was done before the patient arrives in the endoscopy suite and it's overlaid. And so there's always going to be a little bit of what we call CT to body divergence where the airway tree and the virtual target is slightly different from the patient's airways. When they're intubated on positive pressure ventilation. There's a few things we can do to reduce this because as Yogi Berra says, if you don't know where you're going, you'll end up somewhere else when we get out to these lesions. And we do our targeting. That is think of it as navigation helps you find the ballpark targeting, helps you find your seat. We thought when we started doing robotic bronchoscopy that we could just put a tool out and find exophytic tumor in the airways. What we, what we found more commonly is that tumors don't invade airways. And so getting out, getting off access and getting a needle into the lesion. But to much better sampling, robotic bronchoscopy allows you to get out into the airway and visualize these using radial ultrasound, you can sort of get a better view. And with robotic bronchoscopy, you can approach non broncho centric lesions where as tumors can be in the airways, sometimes, especially with hematogenous spread, metastatic disease. Tumors are not associated with the airways whatsoever. And we need to target those effectively as well. Using radial ultrasound, we put a little ultrasound, you can either get an ultrasound signal or not. And so it helps us just narrow our field when we're doing small peripheral lesions. And when we do these lesions in the pereny, we need to be able to manage all of our complications. This is a patient with this tiny nodule. Here in the right upper lobe, we go out, we approach it, we target it with our uh CT overlay and virtual views. I've done my biopsies cured my diagnosis on rapid on site cytology. But you see here that there's bleeding. Now, I'm wedged into this airway. This is a 4.1 millimeter camera wedged into about a three millimeter airway. So I have a good seal and now I have this little micro environment where I'm instilling saline to see the, the bleeding. I know that blood is not getting past me because my scope is nicely wedged and all I do is wait it out after about three or four minutes, the bleeding has slowed and I feel comfortable starting to put out my gold fiducial marker. This patient is going to get SBR TSB RT as you know, uses orthogonal x rays and we put in gold seeds to help with targeting as the, the, the, the the bleeding is has slowed here. You see we've got good visualization. I'm clearly still lined with my target. Here comes the the deployment catheter and then we have a little night and all tailed gold seed. It's about the size of a grain of rice. You see it there in the airways. So bleeding is stopped. Fiducial is in place. Patient is safe and they were referred to radiation oncology for curative treatment. When you have lesions that are close to essential structures, we want to reduce risk even further. This is a preprocedure CT. And we see that this nodule here is between the liver and the heart. Really not a place where you wanna get off access. In the case, we use what's called cone beam CT. This is a portable cone beam unit. We use it with our robotic bronchoscope. And you see this is my biopsy forcep with tool and lesion. So I drive out to the lesion, here's my robotic camera and then put out the biopsy forceps do a 3D spin, able to confirm that I'm not by the heart or the liver and do the biopsy safely with staging we use and linear EBUS these two scopes with ultrasounds on the end of it and we look at all of the lymph nodes. So tumors spread to the lymph nodes regionally. And so we stage in reverse N three. So the more distant lymph nodes and N two and N one. So in the same procedure where we biopsy the nodule, we'll also do full lymph node staging as part of the work up. Now, what's on the horizon, injectable agents now that we can get out to these lesions safely? What can we do to augment treatment, radiation sensitizers, liquid and solid fiducials for um SB RT, as I mentioned, we've just opened a phase one trial looking at oncolytic viruses to inject directly in tumors with a blade of therapies. There's microwave radiation, radio frequency ablation, cryotherapy electroporation. So lots of things coming down the pipeline. How can we augment not replace current modalities? Something I'll show you just on the horizon. This is a study. We just finished using optical coherence tomography. This is a benchtop scanner. I mentioned adequacy is becoming critical when we do our biopsies. Now we can scan them in room looking for areas of tumor. We want to make sure we've got enough tumor to satisfy our our pathologist. And so this scanner, what it does is it scans hundreds of times per second is actually able to predict the molecular activity in the cells and tell us what percent of the sample is tumor, whether we have leal tissues, these are normal and benign and the bronchial cells. And you see how bizarre they become as they, as you see, malignant cells mixed in. This is an adenocarcinoma with a sort of H and E equivalent stain here and, and the um oct scanner and this is an FN A of a lymph node with a cluster of cancer cells that we're able to, to, to recognize. So we do these, we can do procedures like this as on an outpatient setting, safe biopsy and staging Deb breed of, of endobronchial obstruction um in a way that is safe and effective. Thank you.
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