Less Invasive Options for Pulmonary Testing

Dr. Jonathan Puchalski, Less Invasive Options for
Pulmonary Testing
April 10, 2011Welcome to Yale Cancer Center Answers with doctors Francine
Foss and Lynn Wilson.  I am Bruce Barber.  Dr. Foss is a
Professor of Medical Oncology and Dermatology, specializing in the
treatment of lymphomas.  Dr. Wilson is a Professor of
Therapeutic Radiology and an expert in the use of radiation to
treat lung cancers and cutaneous lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu and
the phone number is 1-888-234-4YCC.  This week, Dr. Wilson
welcomes Dr. Jonathan Puchalski.  Dr. Puchalski is Assistant
Professor of Pulmonary Medicine and Director of the Thoracic
Interventional Program or TIP.  Here is Lynn Wilson.Wilson
Let us start off by having you tell the listeners a little bit
about what TIP is.Puchalski
TIP is a collaboration between several subspecialties.  I am a
pulmonologist that went through additional training to become an
interventional pulmonologist, and I work closely with the thoracic
surgeons, the medical oncologists, radiation oncologists and other
pulmonologists in diagnosing and treating both lung cancer and
other benign diseases.Wilson
What is the difference between someone who goes through internal
medicine training and then a pulmonary fellowship, and the
additional training that you did?Puchalski
I did an additional year of devoted time in interventional
pulmonary medicine.  So, directive therapy and advanced
diagnostic and therapeutic procedures that deal with the inside of
the lungs, the airways, and the area that surrounds the lungs
called the pleural space.  Through that very devoted training,
which tends to be procedurally based, that's what distinguishes me
from other pulmonologists and intensivists.Wilson
Tell us a little bit about how these collaborations work. You
mentioned who you work with, but take us through a typical day so
listeners can understand the collaborative nature of your work.Puchalski
On a typical clinical day where I spend time in the clinic with
patients, often I have patients referred for this diagnostic test
or therapeutic tests, but during that time, our thoracic surgeons,
radiation oncologists, and medical oncologists are all working in
the same large clinic space.  So, if there is some test or
some treatment that is better suited for one of my colleagues, we
can easily have them see the people with whom I work and vice
versa.  Many times on a typical clinic day, I may be seeing
the patients on my schedule but also floating into a couple of
other rooms if the thoracic surgeons ask me to evaluate for their
diagnosis or treatment, or the oncologists ask for some advice
regarding airway or pleural diseases.  During the rest of the
week, my typical days are spent performing minimally invasive
procedures, procedures, again, in the airways or in the pleural
space aimed at diagnosing, for example, diagnosing lung cancer or
treating similar things, such as opening up airways or draining
fluid that can sometimes build up around the lungs in an effort to
help people with cancer breathe better.Wilson
What are some of these minimally invasive treatments or procedures
that are offered through the4:29 into mp3 file 
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program? Go ahead and describe them in detail for us; for example,
confocal microscopy, and VATS; tell us about the procedures that
you do?Puchalski
I will start with the pleural procedures, VATS, for example.
 As surgery has advanced, thoracic surgeons, where they used
to need to perform a larger surgery called a thoracotomy, an open
thoracotomy, with new instruments and tools they are now able to
use video assistance to perform a similar thoracic surgery. 
VATS is literally video-assisted thoracic surgery.  They can
make a couple small incisions and perform some of their surgical
procedures completely through these small areas using video
cameras.  In the pleural space, I will perform a similar
procedure called medical thoracoscopy, or pleuroscopy, which uses
just a single entry site into this pleural space to either drain
fluid and, in essence, glue the lung up to the rib cage, so the
fluid cannot come back any more, thereby eliminating the patient's
shortness of breath, which may be caused by this fluid, or even
performing some biopsies in the area, getting some extra tissue to
clarify, perhaps, a patient's diagnosis.In the past several years, we have moved from a fairly large
incision to just a couple of smaller holes with video assistance,
or even one area, where we are able to enter that pleural space in
a very minimally invasive way.  Within the lungs, we can
perform similar minimally invasive tests to diagnose, for example,
lung cancer.  If a patient has what looks like a lung cancer
in an x-ray or a CAT scan, I can use something called a
bronchoscope to go into the lungs, look around the tubes or the
airways that go to the lungs, and either perform biopsies of
visible areas within the airways or go farther out into what is
called the center of the chest, the mediastinum, to diagnose
exactly what is going on.  This is fairly significant. 
These changes have really revolutionized our ability to diagnose
lung cancer, masses in the lung, and nodules in the lung, because
rather than a surgical incision through something called a
mediastinoscopy, we can go right through the airway with no
incisions and use special techniques, that I will describe in a
second, to find these abnormal areas and perform biopsies.For example, endobronchial ultrasound is called EBUS, and EBUS
has a very small ultrasound on the end of a bronchoscope, and using
this ultrasound from within the lungs, we can find the exact
location of a lymph node, the exact location of a mass, perform
biopsies in this area and it's a procedure that may take
half an hour, or an hour and a half, a very short period of time,
and the patient can come in, have the procedure, go home the same
day within a matter of a half day with no incisions and virtually
no significant recovery.  Through EBUS, we are able to
diagnose lung cancer.  We can stage lung cancer and thereby
direct various treatments, whether it is chemotherapy, radiation
therapy, or surgery, for each individual's cancer.You mentioned confocal microscopy.  Confocal microscopy
goes way out into the lungs, into the smallest air sacs in the
lungs to try to see what those look like.  They are called
alveoli, but the confocal microscope can literally look at the
alveoli and give some indications about what is going on far out
into an area that we can never imagine seeing without this
tool.  That tool, specifically, has a ways to go before it's
mainstream, but we are doing a lot of research on it here, and
there are9:52 into mp3 file 
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 other tools.  One is actually called peripheral EBUS, and the
other is electromagnetic navigation, and both of those tools allow
us, through the bronchoscope, to go far out into the lungs and
specifically identify where a small nodule is in the lungs, and
then perform the biopsies in a way that is significantly less risky
than many other procedures, and with greater yield, and more
accuracy than a lot of routine bronchoscopic procedures.Wilson
How does the navigation work?Puchalski
Electromagnetic navigation, you can imagine, is like the GPS system
in your car.  We obtain a CAT scan and are able to identify
specifically where in the lungs, either a mass or a nodule
is.  We put that into a computer and allow our computer then
to talk with the bronchoscope, more or less.  The patient
would come in, the procedure is essentially an advanced
bronchoscopy, we will perform the bronchoscopy, but by targeting
the lesion with the computer, we are able to go into specific
airways that are otherwise very difficult to navigate into. 
Literally, a probe that comes out of the scope will allow us to
both make a left turn and sharp angles that otherwise could not be
done, and then advance this probe out specifically to the area that
we are trying to biopsy.  It is like being at the end point of
your GPS map.  We know where the target is, we can then use
our other biopsy tools to specifically go to that area.  For
peripheral lesions, lesions that are farther out in the lung we
need tools to go out this far, we can perform these biopsies using
EMN and minimize risks, for example, if you need to go through the
chest wall to perform biopsies or a surgical biopsy, with this the
risks are minimal but our diagnostic rates are significantly better
than they used to be.Wilson
This sounds intuitively obvious to me that it is easier for the
patient; it is less invasive.  Is this something that is
commonly available at most centers, obviously with very specialized
training? It sounds like the proper expertise to do this is
required, but why is it that this isn't more widely available? Is
it because physicians simply do not have the training? Is the
technology cost-prohibitive? Why does not every center have the
access to this or the expertise?Puchalski
I think both of those and more. First of all, from my perspective,
it does take additional training to perform this procedure.
 It is something that requires a lot of dedication and
devotion towards specific anatomical landmarks in the lung that
have not always been practiced or even available, this is new
technology, and so as technology emerges, people such as myself,
this is what I do day in and day out, and so now we have these
tools and the training to use these tools that make it different
than a lot of other places.  The other thing is exactly what
you mentioned - it is expensive.  This machine in and of
itself can be upwards of $200,000 to purchase.  It is
certainly something that not every hospital can or should have,
really.  It is something that I think most people in the
country, and in the world, believe should be offered at select
centers for the cost aspects, and also from the expertise required
to perform the procedure appropriately.Wilson
We are going to take a short break for a medical minute. 
Please stay tuned to learn more information about the Thoracic
Interventional Program with Dr. Jonathan Puchalski.14:57 into mp3 file 
http://yalecancercenter.org/podcast/apr1011-cancer-answers-puchalski.mp3Wilson
Welcome back to Yale Cancer Center Answers.  This is Dr. Lynn
Wilson.  Today, we are joined by Dr. Jonathan Puchalski, and
we are discussing TIP, or the Thoracic Interventional
Program.  Jonathan, tell us a little bit about how long it
usually is before cancer is diagnosed.  Say, for example, a
patient might get a chest x-ray that shows something or they might
go to the doctor with a cough or they have problems with shortness
of breath, what usually happens then, say here at Smilow, for
example, with someone of your expertise and caliber, what would be
the next step?Puchalski
You are right, oftentimes, patients will present with any of those
symptoms.  There is not really a specific symptom that
suggests, you have lung cancer if you have this. Clearly a cough or
shortness of breath can be due to a lot of things, but both of
those, typically, will evoke some type of diagnostic
strategy.  A patient may have a chest x-ray, as you said, and
if there is something that does not look quite right on the chest
x-ray, oftentimes the next step is a CAT scan or a CT scan of the
chest.  The imaging is a little bit better than an x-ray, and
so it can detect more specific details than the regular
x-ray.  Depending on what that shows, if we are talking
specifically about lung cancer, there are different spots or dots
in the lung that we will either describe as a nodule or a mass,
both of which we talked about earlier.  A nodule may be a
smaller area that does not look normal, a mass may be slightly
larger, but both of these in a person who may have some of these
symptoms, an appropriate history can certainly raise the concern
for lung cancer.Wilson
And if we saw a nodule that was on the edge of the lung, on this
CAT scan, and it was small, before you were here on the faculty at
Yale, for example, we might try to get a biopsy of that nodule by
putting a needle inside the chest, which puts the patient at risk
for some side effects from the procedure, but with your expertise,
Jonathan, we could attempt the navigation procedure, is that
correct?Puchalski
That is correct.  When these areas are far outside in the lung
closest to the chest wall, we can use either the electromagnetic
navigation we recently talked about or something called a
peripheral endobronchial ultrasound, or peripheral EBUS.  Same
type of idea holds for peripheral EBUS in19:00 into mp3 file 
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that there is a very tiny ultrasound that goes far out into the
lungs to help localize where this nodule or this abnormal area
is.  We can then take the bronchoscope, again, and know that
we are actually within this area by ultrasound or by EMN, and then
perform the biopsies.  The benefit of going from inside
through bronchoscopy is that there is a lot less risk of
complications.  There is something called a pneumothorax,
and this is fairly easy to understand when you
think of the lungs like a balloon.  If you place a needle by a
balloon, the balloon can pop.  So, that is what can happen,
perhaps, 20% or more of the time when we use a needle from the
outside of the lungs going through to biopsy these areas.
 With the emergence of EMN and peripheral EBUS, we can still
go from within the lungs and that risk of popping a hole in the
lungs, or pneumothorax, is markedly less, downwards of 1% or 2%,
and so it really can make a significant difference.
 Pneumothorax usually is not
life-threatening, but it can cause a person to have to stay in the
hospital for a couple of days and have a small tube placed to drain
the air as the lung heals up.  So, it definitely makes things
safer and may prevent some unnecessary complications to help the
patient get home the same day.Wilson
What are some of the different types of lung cancer?Puchalski
In general, when we perform biopsies to diagnose lung cancer, a
pathologist will look under a microscope at the cells in that area,
and upfront they will tell us two main categories.  One is
called small-cell lung cancer and the other is called
non-small-cell lung cancer.  Within the non-small-cell lung
cancer group, there are several varieties; for example, there can
be an adenocarcinoma, a squamous-cell carcinoma, a large-cell
carcinoma, or some other variants, but the pathologist can tell us,
specifically, by looking under the microscope, what a patient has,
and by knowing what the patient has, that can help us direct
specific therapies for the particular patient.Wilson
I see.  Is there a genetic link that we know of for the
development of lung cancer, and how about the environment?
 Obviously, everybody has heard about smoking as a risk factor
for lung cancer, but do we know more about genetics now and their
relationship to lung cancer, and what are some of the other
environmental exposures that could put patients at risk?Puchalski
 You are absolutely right.  Smoking, hopefully by now, is
known by everybody to be directly linked to lung cancer.  We
are learning more and more about the fact of second-hand smoke.
 So, if you are around others who smoke a lot, that may also
be a risk.  There are some other environmental exposures that
can be linked to cancer.  The genetics of it is becoming more
and more understood as we go.  It is actually a very, very
exciting time for medical oncologists or oncologists that treat
lung cancer with chemotherapy, because we are finding different
genetics, or mutations in genes, that were not discovered until
recently.  The importance of this is that I can use some of my
tools to get some tissue, but we can look under the microscope, see
the general type of lung cancer, so small or non-small and various
variants, but then go even further and look at a molecular genetic
level and detect some mutations that may be present within the
cancer cells themselves.  Those mutations then can help us
direct even more specific chemotherapy or other therapies
specifically23:52 into mp3 file 
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at the lung cancer that the patient has.  We are calling this
more an era of personalized medicine where it is not just a matter
of "Oh, you have lung cancer", it is "you have this specific type
of lung cancer, and therefore we can offer you, specific
treatment."  That is actually very exciting for this field
because with more information, we are able to provide better care
for patients.Wilson
Tell us a little bit, Jonathan, about how you are involved in
following a patient who is at high risk for lung cancer, or a
patient with Barrett's esophagus, for example? Tell our listeners
what that is and, obviously, there are x-rays and CAT scans we can
do, but with all of the tremendous expertise that you have with
these minimally invasive procedures, we are able to actually look
on the inside and get a closer look at the linings of the
airways.  What sort of patients do you follow and how do you
do that?Puchalski
Oftentimes, as we have discussed, the patient may have a chest
x-ray, a CAT scan, and then need some further diagnoses.  We
may be able to follow patients based on their CAT scan and not
necessarily every abnormality that is detected on a CAT scan needs
a diagnosis at that time, we may elect to follow things. We are
also at a stage with some of the bronchoscopic tools to detect
very, very early stages of lung cancer that would not have been
detected without this technology.  We have the tools.
 Confocal microscopy, as you mentioned, is used in Barrett's
disease, which often affects the esophagus.  In the lungs, we
can use a similar VAT confocal microscope, look at the airways
trying to detect very subtle changes that cannot be seen with the
ordinary eye in that lining, in the mucosa of the lungs, to detect
if there is, perhaps, a very early-stage lung cancer.  There
are other tools called narrowband imaging, or autofluorescence, and
an emerging technology called optical coherence tomography or OCT,
all of these areas are aimed at going through the bronchoscope,
looking at that lining with these tools, and then being able to
detect very, very small changes early, and if we can detect lung
cancer at an early stage, obviously, we have a much better chance
of curing it completely, and sooner.Wilson
We have talked quite a bit about diagnostic procedures,
interventions; tell us a little bit about some of the things you do
if we have a side effect or a complication from treatment that
develops down the road, as an example, someone gets radiation and
chemotherapy for their lung cancer and hopefully they are doing
well after that, but perhaps they develop a narrowing or a
stricture of one of their breathing tubes from some scar tissue
that is formed.  How would you address that?Puchalski
We can perform therapy now through the bronchoscope, that in this
particular case, if there was a very severe narrowing or stricture,
there are several options.  We could use a very, very small
knife within the airways to make some small nicks to make that
airway larger.  We can use various types of balloons.  We
can literally expand the airway from the inside to increase its
caliber.  Whenever we increase the diameter of the airway,
more air can flow through that airway, significantly, more air can
flow through it, and so a patient's shortness of breath may improve
significantly.  If those do not work, ultimately, we could do
things such as place a stent within the airway.  A lot of
people may have heard of stents in coronary arteries for patients
who have things such as a heart attack, but we can actually put
stents within the airways to help keep these areas open. It may
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after a patient is completely cured from their cancer, and they can
have the narrowing.  We could place stents in there and
patients immediately notice a dramatic difference in their
breathing.  We can also place these stents for cancer.
 If the cancer has grown into the airway and obstructs the
airway, we can put the stents in to help keep it open.  That
is very important to minimize the feeling of shortness of
breath.Dr. Jonathan Puchalski is Assistant Professor of Pulmonary
Medicine at Yale School of Medicine and Director of the Thoracic
Interventional Program at Yale Cancer Center.  If you have
questions or would like to share your comments, visitYaleCancerCenter.org,
where you can also subscribe to our podcast and find written
transcripts of past programs.  I am Bruce Barber and you are
listening to the WNPR Health Forum on the Connecticut Public
Broadcasting Network.