As lung cancer screening starts rolling out across Europe, let’s talk about the next steps - staging and diagnosis

10/12/2021

Every 30 seconds, someone, somewhere in the world dies of lung cancer 1.

Gastroenterology
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Lung cancer is the biggest cancer killer – resulting in 1.8 million deaths worldwide in 2020 2. While the five-year survival rate for lung cancer is 56% for cases detected when the disease is diagnosed early and still localized, this figure drops to just 5% when cancer is diagnosed late (distant tumors) 3. Clearly, there is a need for early diagnosis strategies and yet, only 16% of lung cancers are diagnosed at an early stage 3.

Lung cancer screening to be rolled-out in Europe

Since the symptoms of lung cancer may be mistaken for other problems – such as long-term smoking effects (e.g. chronic bronchitis) – and often do not appear until the disease is already at an advanced stage, diagnosing lung cancer is difficult and frequently delayed. It is possible to dramatically improve early diagnosis and therefore reduce mortality through lung cancer screening.

Currently, only a handful of countries have deployed national screening programs – including Croatia and Poland - but future initiatives are in the pipeline worldwide. To roll out effective national screening programs, hospitals and clinicians need access to reliable and safe technologies. The introduction of low-dose computed tomography screening (LDCT) has greatly facilitated this; producing images of sufficient quality for detection of suspicious areas while using approximately five times less ionizing radiation than a conventional CT scan 4, 5. Moreover, large scale screening trials have demonstrated 15-20% fewer lung cancer deaths among participants screened with LDCT 6, 7. Consequently, the European Respiratory Society (ERS) is now urging countries in Europe to implement lung cancer screening programs 8.

What’s next after screening?
As national screening programs are rolled out and innovative strategies such as LDCT improve early detection, tissue specimen are required to confirm it is lung cancer (diagnosis) and to which degree the cancer has spread (staging). While advanced bronchoscopic imaging technologies (high-definition imaging or extra slim bronchoscopes) help to visualize mucosal changes, endobronchial ultrasound is needed to visualize suspicious structures behind the bronchial wall.

Tissue sampling using flexible bronchoscopy supports accurate staging and diagnosis which is becoming even more important as the use of targeted and personalized therapies and immunotherapies continue to evolve as valid cancer treatment options. In this case, the identification of specific biomarkers or gene mutations through tissue sample analysis and molecular diagnostic tests supports clinicians in determining the best, personalized treatment plans to fight the cancer.

Ensuring clinicians are supported by medical technologies that allow them to identify, sample and test lesions to make definitive diagnosis and staging decisions is therefore a priority (Figure 1).

Figure 1: Access, identify and sample pulmonary lesions with Olympus bronchoscopy solutions.

Lung cancer staging and diagnosis with EBUS-TBNA

Since 2013, the American College of Chest Physicians (ACCP) guidelines on lung cancer diagnosis and management, have recommended endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as the gold standard for mediastinal nodal sampling or comprehensive nodal staging 9 – an important procedure for helping determine the spread of cancer in the lungs.

EBUS-TBNA unites a bronchoscope and an ultrasound probe to enter the lungs and enable the visualization and sampling of mediastinal, central and hilar lesions and lymph nodes within the tracheobronchial tree. Because EBUS‐TBNA is less invasive with a relatively higher yield, it has gradually replaced other procedures – such as mediastinoscopy. 10

EBUS-TBNA can be used for both diagnosis and staging in one appointment, since it provides both tissue diagnosis and nodal staging. In turn, this can minimize the number of steps in the patient pathway, helping to reduce patient intrusion and hospital delays, and ultimately, reduces the time from diagnosis to treatment.

Compared to mediastinoscopy, EBUS-TBNA provides better lymph node accessibility 11, is minimally invasive as it can be performed under local anesthesia, and shows a clear reduction in complications related to staging of lymph nodes 12. A meta-analysis of the available literature also demonstrated a high and consistent diagnostic yield of 90% when using EBUS-TBNA 13.

Augmenting the capabilities of EBUS-TBNA are recent technological developments that assist the staging and diagnosis of even difficult-to-reach lymph nodes and lesions. For example, the new slim Olympus Bronchoscope (BF-UC190F) represents a technology for minimally invasive surgery that couples powerful 160° angulation, a unique compact distal tip and a steep puncture angle. Clinically, this translates to enhanced access to challenging target sites, improved maneuverability, and smooth penetration of the bronchial wall 14, 15.

Getting closer to the periphery: sampling peripheral pulmonary lesions

Accessing peripheral lesions presents a number of unique challenges to diagnosis of lung cancer that can lead to delays in therapy and ultimately, an increased risk of death. Typically, transthoracic needle aspiration (TTNA) is used after a peripheral lesion is detected. While the procedure is well established – with a sensitivity of between 74% and up to 96% - it carries a high risk of periprocedural pneumothorax (between 15-44%) 16. However, advances to technologies mean that peripheral bronchoscopy now represents the least invasive approach to peripheral lesions– with reported pneumothorax rates of just 1.5% 17.

Since the majority of suspicious lesions detected during lung cancer screening are found in the outer third (periphery) of the lung and their location render them difficult to access 18, the thin BF-P190 scope with GuideSheath kit or the ultrathin BF-MP190F/290F scope are designed to support direct access to the periphery. With low complication rates, an overall diagnostic yield of 74% and the ability to reach up to 12 bronchus levels 19, the ultrathin BF-MP190F1 scope has clear clinical value. This ultrathin bronchoscope improves access to deep lung areas, helps approach the lesion, and, in combination with the miniature ultrasound probe, enables real-time imaging of the surrounding tissue - allowing the clinician to determine the lesion's exact location and size.

Alternatively, combining a thin bronchoscope and GuideSheath kit can also help clinicians gain access to peripheral lesions. Once positioned at the target site, the GuideSheath acts like an extended working channel, allowing safe, precise and repeated access to the lesion for sampling. In combination with the GuideSheath, the Olympus radial ultrasound miniature probes achieves over 90% lesion identification 19, 20.

Since 2013, the American College of Chest Physicians (ACCP) guidelines on lung cancer diagnosis and management, have recommended endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as the gold standard for mediastinal nodal sampling or comprehensive nodal staging 9 – an important procedure for helping determine the spread of cancer in the lungs.

EBUS-TBNA unites a bronchoscope and an ultrasound probe to enter the lungs and enable the visualization and sampling of mediastinal, central and hilar lesions and lymph nodes within the tracheobronchial tree. Because EBUS‐TBNA is less invasive with a relatively higher yield, it has gradually replaced other procedures – such as mediastinoscopy. 10

EBUS-TBNA can be used for both diagnosis and staging in one appointment, since it provides both tissue diagnosis and nodal staging. In turn, this can minimize the number of steps in the patient pathway, helping to reduce patient intrusion and hospital delays, and ultimately, reduces the time from diagnosis to treatment.

Compared to mediastinoscopy, EBUS-TBNA provides better lymph node accessibility 11, is minimally invasive as it can be performed under local anesthesia, and shows a clear reduction in complications related to staging of lymph nodes 12. A meta-analysis of the available literature also demonstrated a high and consistent diagnostic yield of 90% when using EBUS-TBNA 13.

Augmenting the capabilities of EBUS-TBNA are recent technological developments that assist the staging and diagnosis of even difficult-to-reach lymph nodes and lesions. For example, the new slim Olympus Bronchoscope (BF-UC190F) represents a technology for minimally invasive surgery that couples powerful 160° angulation, a unique compact distal tip and a steep puncture angle. Clinically, this translates to enhanced access to challenging target sites, improved maneuverability, and smooth penetration of the bronchial wall 14, 15.

The complete solution

Having a single industry partner that can meet your needs across the staging and diagnosis workflow is beneficial in terms of spending visibility, purchasing control, and ensuring consistent quality. In support, Olympus provides a broad and innovative portfolio that covers technologies to assist throughout lung cancer staging and diagnosis (Figure 1). Moreover, Olympus is the inventor of EBUS-TBNA – a technology that has revolutionized respiratory diagnosis, with more than 80% of studies on EBUS-TBNA performed with the Olympus EBUS system and Olympus needles.

The full portfolio includes tools for supporting bronchoscopes for minimally invasive access and allowing adequate and sufficient amounts of sample collection for molecular testing. Olympus offers a full range of specifically designed EBUS-TBNA needle sizes – including ViziShot 2 25-, 22-, 21-, and 19G – for a broader field of diagnostics. Innovative features have been added to the ViziShot 2 portfolio including a novel needle tip design that delivers unparalleled flexibility – allowing clinicians to collect ample quantities of high-quality specimens, even from the most challenging locations. Additionally, a redesigned, sharper needle tip reduces puncture force and resistance for smoother passage, including through cartilage and calcified lymph nodes. Alternatively, the PeriView FLEX represents a dedicated needle for performing peripheral sampling of lesions.

Samples can be subject to rapid on-site evaluation (ROSE) to assess the adequacy of biological materials and achieve all pathological, immunohistochemistry, and molecular analysis. As a complete solutions provider for lung cancer diagnosis and staging, Olympus offers the CX23 microscope for ROSE. Combining a user friendly and ergonomic design with high-performing quality optics, ROSE criteria can be efficiently screened.

Summary

As we transition into a new era of personalized medicine and as lung cancer screening programs are increasingly employed across Europe the time to address the subsequent diagnosis and staging pathways is now. Not only is there strong clinical evidence supporting the use of the Olympus endoscopy and endoscopic ultrasound system, but Olympus is the only manufacturer offering the complete solution for EBUS-TBNA and peripheral bronchoscopy - including dedicated high-end bronchoscopes, needles and microscope. This minimally invasive system from Olympus supports clinicians in collecting good quality samples, safely diagnosing and staging lung cancer patients and ultimately, advancing patient care to save lives.

1some countries use model BF-MP290F

References

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