Volume 07
Issue 01
January 2019
Inside This Issue
Opinion/Editorial, 2, 3
Technology Corner, 4,5
Tips from the Experts, 6,7
Humanitarian News, 8-12
Educaon and Training, 13-14
Best Image Contest, 15
WABIP News, 16
Research, 17
WABIP Academy Webcasts, 18
Links, 18
Upcoming Events, 19
Sally C. Lau, MD
Division of Medical Oncology
Princess Margaret Cancer Center,
University of Toronto, Toronto ON,
Guest Opinion/Editorial
WABIP Newsletter
J A N U A R Y 2 0 1 9 V O L U M E 7 , I S S U E 1
Silvia Quadrelli MD
Buenos Aires,
Argenna, Chair
Hideo Saka MD
Nagoya, Japan,
Zsolt Papai MD
Hungary, Immediate
David Fielding MD
Brisbane Australia,
Guangfa Wang MD
Beijing, China,
President WCBIP 2020
Philip Astoul, MD
Marseille, France,
President WCBIP 2022
Michael Mendoza
General Manager
Judy McConnell
Kazuhiro Yasufuku
Newsleer Editor-in-
P A G E 2
New Immunotherapy Standards for Stage III Non-Small Cell Lung Cancer
Natasha Leighl, MD, MMSc, FRCPC
Division of Medical Oncology
Princess Margaret Cancer Center,
University of Toronto, Toronto ON,
Immunotherapy with immune checkpoint inhibitors is the latest addion to our armamentarium against cancer.
Rather than using cytotoxic compounds that kill cancer cells (and potenally damage normal ssue), immuno-
therapy harnesses the hosts versale immune system. The memory of acvated immune cells is thought to
uniquely correlate with durable responses. Immunotherapy has quickly changed the face of the management
advanced non-small cell lung cancer (NSCLC), and has become a standard treatment in stage IV NSCLC with
emerging data in earlier stages of NSCLC. The use of immunotherapy in stage III unresectable NSCLC has recent-
ly demonstrated improvements in survival compared to standard chemoradiaon alone, with a promise of long
term disease control.
Immune checkpoint inhibitors that are currently used in lung cancer target the cytotoxic T lymphocyte-
associated angen-4 (CTLA-4) and programmed death-1 (PD-1) axis. Under normal circumstances, CTLA-4 and
PD-1 are regulatory systems which aenuates T cell acvaon to prevent autoimmunity.
Upon T cell receptor
(TCR) engagement with an angen presenng cell, a co-smulatory signal from CD28 on T cells is required for
acvaon. CTLA-4 competes with CD28 as a negave regulator, causing arrest of T cell proliferaon.
The PD-1
axis is involved in later stages of T cell acvaon. Interacon of PD-1 on T cells with its ligand PD-L1, which is
widely expressed in non-lymphoid ssues including tumor ssues, results in inhibion of TCR signaling and pre-
vents cytotoxic T cell acvaon.
These systems can be ulized by cancer cells to escape immune surveillance
leading to uncontrolled tumor proliferaon.
Durvalumab, a human IgG1 kappa monoclonal anbody against PD-L1, is the only agent that is currently ap-
proved for the treatment of stage 3 NSCLC. In the landmark phase III study PACIFIC, 713 paents with unresec-
table stage 3 NSCLC, with stable or responding disease aer concurrent chemoradiaon, were randomized to
receive 12 months of consolidaon durvalumab or placebo.
Durvalumab consolidaon signicantly improved
overall survival (OS) compared to placebo (median OS: not reached in the durvalumab group vs. 28.7 months,
HR 0.68 (95%CI 0.47-0.997)).
Median progression free survival (PFS) in the durvalumab group was more than
doubled, (16.8 vs 5.6 months; HR 0.52, 95%CI 0.42-0.65).
The OS and PFS Kaplan-Meier curves demonstrated
that paents beneted early from consolidaon durvalumab and connued to derive benet for the enre du-
raon of follow up (median 25.5 months). Durvalumab was also well tolerated as consolidaon therapy post
chemoradiaon. Importantly, the rate of severe or grade 3-4 pneumonis was similar in durvalumab-treated
paents compared to placebo (3.4% vs 2.6%).
Consolidaon durvalumab aer denive chemoradiaon for
unresectable stage 3 NSCLC is now a new standard of care.
Given the heterogeneity of stage III NSCLC, other potenal approaches for improving outcomes with immunotherapy are under
invesgaon. For stage III paents who are considered to have resectable disease, the role of adjuvant durvalumab remains un-
clear with ongoing clinical trials of adjuvant PD-1/PDL-1 inhibitors aer chemotherapy. Preoperave immunotherapy is also of in-
terest. A pilot study of preoperave immunotherapy examined the use of 2 cycles of neoadjuvant nivolumab (PD-1 inhibitor) fol-
lowed by surgery.
Of the 22 paents who received treatment, 45% of paents achieve a major pathologic response (MPR), ≤10%
of viable tumor cells, and 2 paents achieved a complete pathologic response, raising the possibility of using immunotherapy to
downstage locally advanced disease.
The subsequent phase II NEOSTAR study randomized 33 paents with resectable NSCLC to
neoadjuvant nivolumab or combinaon nivolumab plus ipilimumab (CTLA-4 inhibitor). Preliminary data demonstrates an overall
MPR of 26% (25% in the nivolumab group and 27% in the nivolumab plus ipilimumab group), further supporng a role for neoadju-
vant immunotherapy for resectable NSCLC.
Other clinical trials are ongoing to invesgate the ulity of preoperave immunothera-
py with or without chemotherapy or other novel agents, and will help us dene an opmal approach to those with stage III disease.
The introducon of durvalumab consolidaon as a new standard in unresectable stage III NSCLC post chemoradiaon is only the
beginning. Greater understanding of the biology of stage III disease and the tumor immune microenvironment will help us beer
understand how to harness immunotherapy in this seng and to connue to increase the number of those paents with long term
disease control and cure.
1. Ribas et al. Science. 2018; 359:1350-55
2. Antonia et al. N Engl J Med. 2018; 379:2342-50
3. Antonia et al. N Engl J Med. 2017; 377:1919-29
4. Forde et al. N Engl J Med. 2018; 378:1976-86
5. Cascone et al: Neoadjuvant nivolumab (N) or nivolumab plus ipilimumab (NI) for resectable non-small celll lung cancer (NSCLC), European
Society for Medical Oncology. Munich 2018
P A G E 3
Technology Corner
A Novel Electrosurgery Instrument for Central Airway Obstrucon
Electrocautery refers to the use of electricity for heang, coagulang, carbonizing and vaporizing ssues. The current follows the
path of least resistance and seeks a return back to the electron reservoir. A closed circuit is required, accomplished by a grounding
pad applied to the paent to allow the electrons to leave the paents body. In general, for contact electrosurgery, high-frequency
electric current is delivered through exible or rigid probes of variable diameters. Electrons ow between the delivering probe and
the target ssue. Tissue resistance to ow generates heat that results in dierent eects depending on the generated tempera-
ture: coagulaon (>60-80oC), desiccaon (>100oC), carbonizaon (>200oC) and vaporizaon (>300oC). This essay will describe the
principles and potenal clinical applicaons of a novel electrosurgery tool that integrates contact electrocautery and suconing in
a single catheter. A thorough understanding of the technical principles of this electrosurgery device, as well as clinical applicaons
and associated risks, is necessary before using this device in roune bronchoscopic pracce.
CoreCath 2.7S (Medtronic Advanced Energy LLC, Portsmouth, NH) is a newly commercially available catheter specically designed
for airway use to enable coagulaon, cut and sucon funcons in a single catheter. The catheter is a single use, not reusable sterile
device with an integrated sucon port to evacuate smoke. It reportedly allows for a depth of penetraon of 1.65 mm on cut mode
and 1.9 mm on coagulaon mode. It is acvated by a footswitch connected to an electrosurgical generator, and ulized in electro-
surgical procedures involving removal/cung of so ssues (excision, incision, vaporizaon, ablaon) while also providing electro-
surgical coagulaon and hemostasis (Figure 1). Similar to other thermal ablave modalies, high power sengs may result in deep-
er ssue eects than lower power sengs. The depth of eect is deeper and also increases with me if the electrodes are held
staonary, with less depth of eect if the electrodes are moved over the target ssue. The catheter is being acvated by a by
pressing the CUT or COAG pedals on a wireless footswitch. The sengs can be adjusted as needed for desired ssue eect. In gen-
eral, the electrode is held on the target ssue for 2-4 seconds to achieve opmal ssue eect. It should not be acvated connu-
ously to avoid over-treatment of ssue and potenally airway wall perforaon. If the eect is insucient, the power can be in-
creased on the generator unl opmal sengs are achieved. The power changes should be in increments of 5 was in the range of
0 to 40 was on CUT, and in increments of 5 was in the range of 0 to 20 was on COAG. We suggest operators use the lowest
seng possible to achieve the desired ssue eect to avoid over-treatment.
Potenal Clinical Applicaons
CoreCath is indicated for obstrucons in central airways by providing electrosurgical hemostasis and suconing of the coagulated
and charred ssues. In terms of set up, like with any electrosurgery device requiring grounding, operators should assure that the
area of the paent return electrode placement has adequate surface area, musculature, and vasculature for the ancipated cur-
rent and duraon of use. As this is a thermal ablave therapy instrument, it should not be used in cases in which the fracon of
inspired oxygen (FiO2) exceeds 40%. Although in the Instrucons for Use (IFU) manual, the manufacturer states the device should
be used through the exible bronchoscope, we believe it can be safely applied though the rigid bronchoscope as well. In fact,
smoke generaon may sll occur despite the built-in sucon lumen, but in general can be managed by applying sucon while using
this catheter through the 2.8 mm working channel bronchoscope or by ushing the catheter. Alternavely, the CoreCath can be
inserted through the rigid bronchoscope in which case the rigid sucon catheter can further facilitate smoke evacuaon (Figure 2).
A blue visual indicator at the distal end of the device informs the user when the CoreCath has passed through the full length of the
bronchoscope and is ready for acvaon. During the actual applicaon, there is a need for a gentle forward advancement of the
device in order to cut through the ssue. It is recommended to keep the electrode p in moon (not just forward but also rotang
movement) while acvated, to avoid excessive eschar buildup. Excessive eschar buildup can compromise device performance, in-
cluding reduced or clogged sucon. Indeed, we found that an actual helical movement by slightly advancing and rotang the cathe-
ter may be more ecient as the sucon port doesnt get obstructed by charred ssues that easily. If that happens, however, the
device may be removed for cleaning to avoid having excess ssue char buildup on the electrode. This should be done by carefully
pulling the catheter and remove it from the bronchoscope, followed by a gentle clean with a damp cloth or damp gauze, while
P A G E 4
making sure not to deform the device p. Sharp objects such as needles should not be used to clean the electrode as they could damage
the device and compromise performance. Aer cleaning, bronchoscopists should inspect the electrode p before using it again to assess
its integrity. While not in use, it is recommended to place the electrosurgical device in a clean, dry, non-conducve and highly visible area
away from the paent. This will avoid paent injury and inadvertent combuson in the procedure suite in case of accidental device acvaon.
In our experience with this device, the sness of the catheter might preclude its use in the upper lobes in some paents. One other poten-
al concern is the lack of opmal tacle feedbackas the catheter is advanced in the tumor for debulking. While we are not aware of ad-
verse events to date, it is possible that the inability to feel the interface between the tumor and the normal airway wall while advancing the
catheter could lead to airway perforaon. In addion, we do not use this device for segmental airway obstrucon. The use of CoreCath
around airway stents can be useful for signicant tumor or granulaon but a direct contact with the stent should be avoided.
As the experience with this device is just now emerging, we suggest bronchoscopists should have alternate means for hemostasis if bleed-
ing connues. As with other electrosurgical devices, precauons are warranted in paents with pacemakers, debrillators or other elec-
tronic implants. The bronchoscopist should clarify with the manufacturer whether the device is contraindicated in such cases.
CoreCath 2.7 S is a single use electrosurgery device that integrates coagulaon, cung and suconing and can be used during exible and,
in our experience, during rigid bronchoscopy as well. These features have the potenal to make it a versale tool in the armamentarium of
devices available for treang central airway obstrucon. Bronchoscopists should understand its physics principles, power sengs, coagula-
on, cut funcons and clinical applicaons. Device evaluaon and comparave trials will need to assess safety and dene the lesions that are most
likely to benet from this technology.
1. Barlow DE. Endosc. 1982;28(2):73-6
2. Bolliger CT et al. Eur Respir J. 2006;27(6):1258-71
3. hps://www.medtronic.com/content/dam/covidien/library/us/en/product/intervenonal-lung-soluons/corecath-2-7s-electrosurgical-device-
informaon-sheet.pdf; accessed on 12/8/2018
4. Medtronic CoreCath 2.7S Instrucons for Use. manuals.medtronic.com; www.medtronicadvencedenergy.com
W A B I P N E W S L E T T E R P A G E 5
Figure 1: CoreCath 2.7 can be delivered through a exible or
rigid bronchoscope; the catheter is gradually advanced unl
the blue band at the distal end of the device appears on the
monitor. Then the device is ready for acvaon. If catheter
does not advance easily, bronchoscopists should rotate device
slightly while advancing.
Figure 2: Top le panel: Complete distal le mainstem bronchial
obstrucon by tumor protruding from the le upper lobe; Top mid-
dle panel: tumor resecon using the CoreCath; note the area that
was just coagulated and suconed out by the CoreCath (blue arrow).
Top le panel: note the three areas post CoreCath resecon (blue
arrows); Boom le panel: paral tumor resecon allowed inseron
of the rigid sucon catheter and aspiraon of secreons from the
le lower lobe; Boom right panel: patency to the le lower lobe is
Tips from the Experts
P A G E 6 V O L U M E 7 , I S S U E 1
Definitions and Epidemiology
All pneumothoraces are not created equally and the dierences are important as they inform further management strategies. Of the three
categories (spontaneous, traumac, and iatrogenic), management for spontaneous pneumothoraces requires the most thought. This cate-
gory can be primary (no preceding trauma or underlying precipitang cause such as lung disease) or secondary (occurs in paents with un-
derlying structural lung diseases). I will be focusing on primary spontaneous pneumothorax (PSP) which seems to have the most unique fea-
tures and cause for debate.
While the exact incidence is not known, PSP occurred in approximately 18 per 100,000 males and 6 per 100,000 females among a popula-
on around Stockholm, Sweden from 1975 to 1984.
It is most common in males aged 15-34 who are tall and thin. However, the strongest
risk factor is smoking (tobacco or cannabis).
As sub clinical emphysema-like changes (ELCs) have been reported in up to 80% of paents
with PSP, bleb rupture along the visceral pleura is a popular theory for the pathogenesis of PSP. However, other theories like visceral pleural
porosity have been proposed, so the exact cause of air leakage in PSP is not enrely clear.
Management of the rst episode of PSP
One thing that is agreed upon is that paents with this disorder rarely present with tension physiology or respiratory distress unlike those
with secondary spontaneous pneumothoraces (SSPs) who have less pulmonary reserve. Even though most paents with PSP present with an
abrupt onset of pleuric chest pain with or without breathlessness, many paents will have minimal to no symptoms. The Brish Thoracic
Society (BTS) Guidelines from 2010 remind us that we have me and we should adopt a more conservave approach with greater reliance
on clinical symptoms to dictate management and minimize painful procedures when possible. In contrast, the earlier American College of
Chest Physicians (ACCP) guidelines from 2001 recommended tube thoracostomy for any pneumothorax greater than 20% of the hemi thorax
regardless of symptoms.
Simple aspiraon without tube thoracostomy can be very successful in treang the rst episode of PSP that is large or causing symptoms, so
much so, that simple aspiraon is recommended up to 2.5 liters of air, at which point, conversion to tube thoracostomy is recommended.
The procedure is easily accomplished by inserng a 16 to 18 gauge angiocatheter typically into the second intercostal space, mid clavicular
line and connecng to a 3-way stop cock for evacuang pleural air with a large syringe. This strategy has been shown to decrease the need
for hospitalizaon. Considering the litany of user friendly small bore thoracostomy tubes on the market, one could argue that an eight
french pleural drain could be used rst line as well as simple aspiraon. It should not add signicant discomfort and could prevent the need
for a second procedure if simple aspiraon fails (i.e., air leak persists even aer 2.5 liters is aspirated). If the air leak resolves and follow up
imaging shows lung re-expansion, then the paent may be discharged the same day without need for hospitalizaon. Simple aspiraon for
PSP fails 25-50% of the me and there is no evidence to support a second aspiraon rather than chest drain inseron. Alternavely, dis-
charge with a one-way Heimlich valve aached to the chest drain is another opon to prevent hospitalizaon.
Local equipment, paent
and facility logiscs, and experse play a role in choosing among these opons.
Prevenon and Management of PSP recurrence
Management of Primary Spontaneous Pneumothorax
Nicholas Pass, MD, FCCP
Associate Professor of Medicine
Medical University of South Carolina
Division of Pulmonary and Crical Care
Tips from the Experts
P A G E 7 V O L U M E 7 , I S S U E 1
Aer treatment of PSP, paents want to know the next step and what can be done to keep it from happening again. Unfortunately, in the
absence of a large body of evidence, this topic is one for debate. It should be considered that the recurrence rate for PSP is less than that of
secondary spontaneous pneumothoraces (30% vs. 50%, respecvely) and paents will generally tolerate recurrent PSP more favorably with
less risk of pulmonary decompensaon than paents with SSP. So, unless the paent engages in high risk professions (e.g., scuba diving, air-
cra personnel), has a persistent air leak for longer than 3 to 5 days, has a hemopneumothorax, or has bilateral pneumothoraces, a preventa-
ve pleurodesis procedure can be delayed aer the rst episode of PSP. Surgical management (bleb or bullectomy with paral or complete
pleurectomy and mechanical or chemical pleurodesis) has reportedly lowest rate of recurrence (<5%) and should be considered for the rst
recurrence of PSP since a second recurrence can be expected approximately 60% of the me.
Figures 1 and 2 are images from a 17 year
old male student who developed an abrupt onset of chest pain without breathlessness while walking to class. The case highlights the benet
of a muldisciplinary approach of pulmonologist recognizing a primary spontaneous hemopneumothorax and treang with tube thoracosto-
my due to blood in the pleural space. Subsequently, a thoracic surgeon was consulted due to the hemopneumothorax and the paent was
taken for successful video assisted thoracoscopic surgery (VATS) with bleb resecon and mechanical pleurodesis.
A more complicated issue is the management of recurrent PSP aer mechanical pleurodesis. Repeat VATS would be indicated for a complete-
ly failed pleurodesis (when a sizable pneumothorax is clearly idened). However, on occasion, these paents have small, loculated recurrent
pneumothoraces that are not easily accessible to drain but yet are responsible for recurrent chest pain. Pain medicaon, reassurance and
monitoring may be the most reasonable approach in these scenarios.
In conclusion, the literature supports simple aspiraon in symptomac individuals with a rst presentaon of PSP. Other management con-
sideraons may include small bore chest drains and consideraon for the use of Heimlich valves. In high risk groups at rst presentaon or in
paents with recurrent PSP, denive management with a thoracoscopic pleurodesis procedure should be pursued. As chest physicians, we
should also counsel paents on the need for smoking cessaon to reduce the chance of PSP recurrence.
1. Bense et al. Chest 1987;92:1009-12.
2. Withers et al. Am J Surg 1964;108:772-6.
3. MacDu et al. Thorax 2010;65:ii18-ii31.
4. Tschopp et al. Eur Respir J 2015;46:321-5.
5. Tschopp et al. Eur Respir J 2002;20:1003-9
Figure 1: While a conservave approach is generally favored for the
rst PSP, cases like this of hemopneumothorax (thought to be due
to bleeding from small vessels associated with sub pleural blebs
that rupture) can be considered for surgical management of the
rst event.
Figure 2: CT scan of the chest on the same paent with PSP showing
sub pleural emphysema like changes at the le lung apex
Humanitarian News
W A B I P N E W S L E T T E R P A G E 8
The Ethics of Migraon
Ethical quesons regarding human migraon are a topic of hot public debate, parcularly in recent years. The consequences
of human migraon have received much aenon in polical theory, internaonal law, internaonal relaons theory and
internaonal human rights discussions. However, most of those discussions are based on the economic impact and the legal
status of immigrants. But the essenal point is how to dene an ethics of immigraon, to dene what is morally right and
wrong, and not just about what is ecient or good for some segment of the populaon. The juscaon of whichever the
migraon policies chosen by any country should be based on moral grounds.
The term migrantrefers to anyone living or working outside their home countries, from low-wage workers to very wealthy
expatriates. A United Naons report states that the number of internaonal migrants reached 244 million in 2015, with ap-
proximately 20 million being refugees and the rest considered as economic migrants. Although migrant workers are vital to a
country's economy, many of them, especially low-wage laborers, generally have limited rights in their receiving countries
and are vulnerable to discriminaon and abuse.
Migraon is the basic story of the human race from its origins to the present. People have always moved, in search of food
or escaping from the dangers of the war. Or simply looking for beer opportunies for their families. Almost every single
human being all over the world is a descendent of a migrant. Some sciensts esmate that the migraon could have begun
as early as 100,000 years ago and that contact with more archaic populaons like the Neanderthals could have produced
changes in what became the modern humans. But beyond some academic dierences between scholars, no sciensts have
disputed that ancestors of the human species (all of us) originated in Africa.
Human migraons have transformed completely the lands themselves and mainly the racial, ethnic, and linguisc nature of
their populaons. Europe, is the product of several early migraons as diverse as the Germanic peoples, the Slavs, and the
Turks. The Americas, Australia, Oceania, the northern half of Asia, and some regions of Africa have been quite recently colo-
nized by European migrants. The total number of Europeans reaching the United States amounted to 37 million between
1820 and 1980 and currently over 20% of Canadas populaon is made up of immigrants.
In the current world, 3.2% of the worlds populaon are internaonal migrants. Migrants are an heterogeneous populaon:
refugees escaping from persecuon, persons displaced by environmental factors, people seeking for employment and even
rered persons looking for cheaper locaons and beer climate. The percentage has remained stable for years, and curious-
ly, emerging economies (Brazil, India, China) and oil-producing countries are now receiving the majority of migraon, that
consequently takes place mainly towards the Southern hemisphere. In spite of those uncontroversial facts, states in the
Northern hemisphere are disproporonally concerned by a fear of "invasion" by poor migrants from the South.
As a result of ever-increasing controls on migraon, the vulnerability of migrant persons to violaons of their human rights is
increasingly exacerbated.
Migraon that happens through visa categories tends to fall into three general categories: family migraon, employment-
based migraon, and humanitarian migraon. All migraon is however to some extent underlined by economics, because
restricons to migraon, specically in wealthy states, operate privileging the few and the wealthy, restricng the many and
the poor. In many industrialized states, a family-based peon is required to show proof of income. Student visas require
the applicant to prove they have sucient funds to live in the host country. On the other hand, the worlds leading experts,
Humanitarian News
W A B I P N E W S L E T T E R P A G E 9
elite sport men and women, highly qualied arsts or intellectuals and the super-talented are selected as the winnersof
the prize of cizenship and wealthy countries compete to aract them. Like it or not, global inequality is at the heart of the
debate of the ethics of internaonal migraon. We have to admit that it would be the height of hypocrisy to deny that the
problem are not immigrants but poor immigrants. The wealthy and/or polically powerful immigrants are always welcome in
most of the sociees.
Interesngly, migraon is generally viewed as an individual choice, without taking into account that most of the mes, fac-
tors out of the individual control, such as loss of land, natural or man-made disasters, polical instability, poverty and mainly
economic and polical policies and acons of the local government, neighboring governments, or super-powers may create
an eect that results in forced decisions to migrate that are far from the individual choice of the migrant.
One of the most used moral argument to support limits on immigraon assumes that any country has a limited pool of
goods, that if they are allowed to be consumed by immigrants from developing countries will be less available for cizens. It
is argued that immigrants are usually ready to work for less than cizens, decreasing wages in the labour market. Or that
immigrants use government services as educaon and health care that are supported by cizen taxes. From that point of
view, naons would have the moral right to exclude immigrants because they harm cizens.
Although popular, those asserons are simply false. The quanty of goods a naon produces is not xed and usually, the
larger a naon's labor pool, the greater its producve potenal. Immigrants add to a naon's labor pool, and they increase
the naon's producve potenal, increasing the available goods. Addionally, when immigrants turn into workers, they also
turn into new consumers and they contribute to the growing of economy.
On the other hand, most of the mes, immigrants do not use government services in a signicant degree. In most of the
countries, in order to access to social services provided by government, people have to pay the same income and social se-
curity taxes that cizens pay to support these services. In fact, in most of the wealthy economies immigrants subsidize
healthcare for locally born individuals by paying in more to the system than they withdraw as in most of the host countries
immigrants use far less healthcare resources than persons born there. A recent study has found that immigrants make up
12% of the populaon, but only account for 8.6% of total U.S. healthcare spending. (Flavin, L., Zallman, L., McCormick, D., &
Wesley Boyd, J. (2018). Medical Expenditures on and by Immigrant Populaons in the United States: A Systemac Review.
Internaonal Journal of Health Services, 48(4), 601621).
But even in countries with a wide and easy access to government services, where an undocumented immigrant can get ac-
cess to services as educaon and healthcare, the proporon of the burdenof immigrant use is not really relevant as they
usually do not represent more than a small proporon of users. Inequalies in accessing health services for undocumented
or irregular migrants are not only based on poverty, they are also due to language, costs, locaon, informaon, or fear of
refusal, all reasons that create what has been called the Exhausted Migrant Eect(Domnich A, Panao D, Gasparini R,
Amicizia D. The healthy immigranteect: does it exist in Europe today? Ital J Public Health. 2012;9:17). Addionally, fol-
lowing some perverse Darwinian logics of migraon, the disparity in healthcare spending may be also due to a healthy im-
migrant eect,meaning that recent immigrants tend to be young and robust when they arrive. Currently, undocumented
immigrants account for 1.4 percent of total medical expenditures in the U.S. even though they make up ve percent of the
populaon and in the UK, health tourism(people that come to the United Kingdom with the express intent of using health
services to which they were not entled), was esmated to cost only £60 million of the annual NHS budget of £113 billion
(The Kings Fund Report).
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W A B I P N E W S L E T T E R P A G E 10
In general, most of the studies sustain that the economic costs of immigraon are counter-balanced by the less obvious ben-
ets of job creaon, expanding producvity, and added tax revenue.
Unfortunately, many mes the real reason of public concerns about immigrants is covert racism. Immigrants speak a dier-
ent language; their skin color is dierent; they have a dierent culture and behave dierently. And many cizens just do not
want to live side by side with people who are dierent.
For the medical community, the most specic topic requiring moral discussion is the access to health care. The United Na-
ons Commission on Human Rights resoluon 2000/48 arms that every State party to the Internaonal Covenant on Eco-
nomic, Social and Cultural Rights must undertake to guarantee that the rights enunciated in that Covenant will be exercised
without discriminaon of any kind, including on the basis of naonal origin”.
Many countries have or are studying to create laws in order to restrict the free access of certain groups of migrants to the
medical treatment provided by the government services. The central queson is if this discriminaon can be supported on
ethical terms, and which would be the moral argument to jusfy those decisions.
There is an increasing body of ethical literature that quesons the usual view that accepts that every state or naon has the
right to decide who can inhabit or not in that parcular country. Naonal borders are morally quite arbitrary as they usually
are the result of war, geography or discovery; and they may even change during a single individual life-me. From a liberal
point of view, naonal borders do not bear much moral weight. Going even further (although knowing that it is very contro-
versial point of view and quite contradictory to the ordinary common sense”) Joe Carens (a professor for the Department of
Polical Science at the University of Toronto) in his last very awarded book The Ethics of Immigraonargues for open bor-
ders. He supports the idea that restricons on immigraon are ulmately a way of protecng privilege and that our current
society resembles too much a model everybody thinks is wrong, like the feudalism was. The rich countries are like the few
limited members of nobility were in the feudal system and the vast majority of people in the world who live elsewhere, are
poor and impoverished like the peasants in the serfdom mes.
Given the obvious arciality of states and the historically arbitrary and morally dubious ways in which those states came to
have their boundaries, many scholars of internaonal law and human rights are tempted to wish those borders away in favor
of a universal human community of individuals. However, there is a history behind the current arrangement of state naons
as the result from the wars of 16th- and 17th-century Europe, all based on the intenon of re-imposing a universal and
"correct" order on the religiously broken post-Reformaon world. And that is not going to be changed so easily.
Consequently, that is a dicult posion to be accepted for many cizens all over the world. But it clearly shows the contra-
dicons of our ethical foundaons. We members of civilized”, liberal democrac naons are supposedly commied to free-
dom as a basic human right, but then we keep people from freely moving. Probably, what this discussion about borders
stresses, is mainly that the soluon is not to get everybody moving from countries in despair to wealthy countries, but to
transform the condions for that people not to feel compelled to move. And to accept the search of that achievement as a
moral global responsibility. In Carens words, open borders is not a goal in itself, is not a policy proposal (it is not praccal
and it is probably not acceptable nowadays). The main goal is to work towards creang a world where open borders can
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W A B I P N E W S L E T T E R P A G E 11
The point is that if we want to keep in the liberal philosophy, nding moral basis for restricons to non-cizens is a very di-
cult task. On a classical liberal theory, the dierence between a world of liberal communies and a world liberal community
is not of fundamental importance. Since the aim of government in a community is to assure the basic liberty and property
rights of its cizens, borders are not of great moral signicance in classical liberalism. Taking that into account, as recently
stated by Phillip Cole (from Middlesex University) nding reasons to restricon of welfare for non-members of a society
would require to adopt versions of liberal communitarianism (more than the classical liberal views) that x on the naon as
having moral value, and jusfy pracces of discriminaon between members and non-members. It means that is the parcu-
lar community and not humanity or personhood in general, which gives rise to ones strongest moral dues. It requires to
accept that the principle of community outweighs the principle of humanity. A dicult principle to accept for most of schol-
ars and for ordinary people.
Many argue that the reason that support rights to welfare is the contribuon to the economic through work and taxaon.
However, even if it is supposed that members of a naon have made these contribuons (which is not always true), in a
globalised world economy, the idea that cizens of a naon state are the only ones who contribute to the economic prosper-
ity of that state, is dicult to sustain. And at the same me, many cizens make lile or no economic contribuon and many
migrants do (as they work and pay taxes).
We may want instead to argue that the other liberal states should take care of their own cizens, but in that case we should
accept that these other states are of no moral concern to us. What is a problem. Because it cannot be sustained without
abandoning the classical commitment to universalism of the liberal theory.
Aer analyzing all these failing ethical juscaons, Phillip Cole (Cole P Human rights and the naonal interest: migrants,
healthcare and social jusce Journal of Medical Ethics 2007;33:269-272), nds only one opon for accepng the discrimina-
on between members and non-members without abandoning the liberal polical theory. He calls that opon liberal real-
ism”. That is a concept coming from internaonal relaons theory which considers the internaonal order as dangerously
anarchic and, consequently, supports that the only raonal approach for naon states is to defend their self-interest. It re-
sembles the Hobbesian view of the internaonal order, as a dangerous natural condionin which other states are poten-
al threats and it gives right to stop morality at the naonal border. Obviously this approach denies any possibility of global
social jusce.
Accepng liberal realism means accepng that liberal instuons included the welfare system must be protected by illiberal
pracces, just protecng the naonal interest without any other ethical concerns. It means accepng that a liberal democra-
cy cannot sustain liberal instuons without restricng membership and access. It does not require an ethically grounded
disncon between cizens and migrants, it does not jusfy these decisions ethically but just accept this necessary discrimi-
naon on praccalies. A principle dicult to harmonize with John Rawls' Second Principle of Jusce of his A Theory of Jus-
ce, that "social and economic inequalies are to be arranged so that they are to be of greatest benet to the least-
advantaged members of society". Although it is true that in his late works, this icon of the philosophy in the liberal tradion
became himself quite restricve about the applicaon of his principles globally, surprising many of his fellow egalitarian lib-
The truth is that most of ethical theory, sll think that there is no way of nding a moral argument for restricng migrant
access to the welfare system, and that this is a profoundly amoral decision. Accepng this liberal realismmay mean going
as far as accepng the idea that internaonal human rights and the queson of global jusce have no place within liberal
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
polical theory, and that the defense of liberal instuons by liberal naon states is based only on the fact that they are
their instuons and not because those who choose to support them are liberal individuals. They just defend instuons
that benet themselves, not necessarily following a certain ethical juscaon. Those implicaons (following Cole) show
liberal realism as a shallow and brutal philosophy”.
The ethical foundaons of migrant policies concern to all the health care workers. No full agreement if going to be found
soon. But, denitely, what health care workers cannot help is to avoid the point. We have to study the praccal implicaons
based on facts and not undocumented beliefs and we have to make a choice about our ethical posion regarding to the poli-
cies we want our government to adopt. We cannot just ignore the topic, as it is, no doubt, absolutely in our lane”.
*The views expressed in this arcle are those of the author and do not necessarily reect the ocial posions of the Execu-
ve Board or Internaonal Board of Regents of the WABIP. Dr. Silvia Quadrelli is Vice-chair of the WABIP.
Figure 1: Congratulaons to everyone who parcipated in the Train-the-Trainer and introducon to Flexible Bronchoscopy course held in Bue-
nos Aires, Argenna, 2018.
Another generaon of South American leaders, Buenos Aires, 2018
Its always excing when a new generaon of physicians takes on leadership roles. That is what I saw in Buenos Aires in December, 2018. This
train the trainer program included physician-leaders from Argenna, Chile, Peru and Uruguay. The course was led by Dr. Hernan Iannella and
Dr. Iris Boyeras from Buenos Aires, coached by veteran Master Instructor Patricia Vujacich, ending with a fantasc Introducon to Flexible
Bronchoscopy program held at the Pediatric Society building in Argennas capital city. The Argenne group has incorporated Bronchoscopy
Educaon Project materials (assessment tools, checklists, step-by-step, praccal approach exercises) in their yearly bronchoscopy cercaon
course since 2009. Also, I can not thank enough my argenne friends and senior instructors Artemio Garcia, Silvia Quadrelli, Patricia Vujacich,
Pedro Grynblat, Ricardo Isidoro, Fernando Galindez, and Hector Difranchi who contributed so very much to the development and eventual dis-
tribuon of teaching materials, including The Essenal Bronchoscopist series of books around the world!
Parcipants in the Buenos Aires program enthusiascally aacked case-based Praccal Approach exercises and Informed Consent role-playing
scenarios, incorporang newly learned technique of coaching into their teaching sessions. It is noteworthy that this was the rst generaon of
future instructors who have already been totally trained using bronchoscopy educaon project materials during the course of the pulmonary
training. Ample me was provided, therefore, for mastering Bronchoscopy Step-by-step teaching methodology, and for praccing how to incor-
porate assessment tools such as the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) and checklists into daily teaching. Several sessions
focused on exchanging viewpoints about teaching, reecng on ones own teaching and learning techniques, and discussing how clinical service
(day to day paent care) can be separated from focused teaching in order to teach more eecvely and eciently. The group unanimously be-
lieved that paents must be spared from being used for pracce, and all believed that in todays day and age, models, rather than paent or
animals should be used for procedural-based educaon.
It is noteworthy that all teaching materials are available in Spanish, and can be downloaded from the Bronchoscopy Internaonal website at
www.Bronchoscopy.org. Once more, Bronchoscopy Internaonal faculty partnered with the World Associaon for Bronchology and Interven-
onal Pulmonology to conduct a state of the art educaonal program with long-lasng impact. A special thank you goes to Hernan Iannella,
who has diligently help perfect the Spanish translaons of teaching materials, and to Chilean thoracic surgeon and next president (host) David
Education and Training
P A G E 13
Lazo, who plans to incorporate Bronchoscopy Educaon Project materials in courses promoted during the next South American Associaons
regional bronchology meeng in 2020.
December marked the last of 2018’s Train-the-Trainer programs. While several other educaonal programs are scheduled for 2019, only one
(Algeria) is a Train-the-Trainer. Needs assessments have idened a need and desire for programs in Africa, the Middle East, and Eastern Eu-
rope. Please contact Michael Mendoza or Henri Colt to discuss scheduling for 2020, and keep checking the Bronchoscopy Internaonal and WA-
BIP websites for new educaonal materials and announcements.
Figure 1 A: Physician trainers in Buenos Aires working on a case-based Praccal
Approach exercise in Buenos Aires, Argenna. Figure 1 B: Students learning Step-by-Step
using the TruCorp airway model and Olympus videobronchoscope. Figure 1 C: Trainers
conducng an Informed Consent Role-Playing exercise.
Education and Training
P A G E 14
We are most grateful to have received over 150 images for parcipaon in this Image Contest. Aer a thor-
ough review of all images by the WABIP Academy Image Library Editors, we are proud to announce and show
the rst of three best images from the contest. The remaining best images will be released in the next two
issues of the Newsleer.
Descripon: Refractory hydrothorax appears when there is no response to sait restricon, diurecs and para-
centesis and its management is not well established. Videothoracoscopy is a promising therapy that permits
the detecon and closure of diaphragmac defects, and when used with talc pleurodesis resulted in long-
lasng control.
Contributor: Salvato Feijó, M.D. (France)
WABIP Member Society: Groupe d'Endoscopie de Langue Française
Best Image Contest
P A G E 15
Annual Board of Regents Meeng 2019
As the new business year is upon us, WABIP Regents (member society
representaves) shall meet and vote on WABIP acvity and nancial re-
ports for our annual lings as a non-prot organizaon in Japan. The
meeng shall take place in the Gold Coast, Australia at the Asia Pacic
Congress for Bronchology on March 29, 2019 (website:
www.apcb2019.com). Regents who cannot be in aendance at the
APCB shall be provided the documents for review and vong via online
WABIP Vising Scholar Travel Grant Recipients 2019
Aer receiving over a dozen of highly qualied applicaons,
we have nally narrowed down the candidates to two nal
recipients. We are proud to announce two WABIP Vising
Scholar Travel Grant recipients, which will go to Dr. Desh
Deepak (India) and Dr. Mia Elhidsi (Indonesia). Dr. Deepak
shall be travelling to Maryland, USA and conduct a 3 week
observership program under supervisor Dr. Joseph S. Fried-
berg. Dr. Elhidsi shall undergo her observership in Marseille,
France under supervisor Dr. Hervé Dutau. Their learning ex-
periences shall be included in future WABIP Newsleer is-
New Member Sociees
We are delighted to announce two new member sociees: Senegal Bronchology Associaon and the Ghana
Thoracic Society. The two sociees are represented by Prof. Khady Thiam (Dakar, Sénégal) and Dr. Jane San-
dra Afriyie-Mensah (Accra, Ghana), respecvely.
As a truly internaonal organizaon, the WABIP is proud to connue promong global unity in intervenonal
pulmonology. As of January 2019, the WABIP consists of over 8,600 members represenng 60+ countries and
ve regions of the world.
P A G E 16
The Holy Grail?
The desire to reach smaller and peripheral pulmonary nodules connues to grow stronger as the screening for lung cancer becomes more prev-
alent. Aer which, the natural next step would be the ability to ablate/treat them. Currently, there are several limitaons in reaching small and
peripheral lesions; including the size of the bronchoscope, availability or lack thereof a guidance or navigaon system and conrmatory technol-
ogy that would work with smaller scopes. Current navigaon systems have improved the yield of transbronchial biopsies to a great extent, How-
ever, among other issues, the human factor/operators skill and instrument size pose some limitaons.
Recently, innovave roboc bronchoscopic systems with built-in navigaon and sensor technology and constant tracking of the micro-
instruments may provide even more accuracy and consistency in higher yield. These devices are operated from a video-game like a console
once the scope is in the airway. The systems are equipped with sophiscated pressure/resistance feedback system similar to human tacle
feedback for easy navigaon. The intuive and user-friendly interface makes the operaon of this device simple and fun. Roboc bronchoscopy
is done under general anesthesia via an endotracheal tube. The roboc scope is threaded into the endotracheal tube. The working channel of
the bronchoscope allows for sucon and exible micro-instruments to pass. The built-in navigaon system of the roboc bronchoscope allows
for precise localizaon of the target. Once the scope is in the endotracheal tube, it can be controlled with a joysck or a mouse like control to
drive the bronchoscope in the airway. Sophiscated soware allows the roboc scope to make sharp turns and negoate dicult contours of
the airways precisely. Recently, some early data has been published for two roboc bronchoscopy systems: these two systems.
One of the studies with the Monarch system suggests (1) high success rate for obtaining successful biopsies and minimal complicaons. In this
study the system worked eciently and eecvely.
Another study (2) of roboc bronchoscopy system made by Intuive Surgical was tested
in its rst human study in Australia on 30 paents’. The diagnosc yield with this system
was 83% for all lesions and 89% for malignant lesions. The system appeared to be
ecient and safe.
Roboc bronchoscopy is yet another step towards our sincere desire to serve our
paents with pulmonary nodules beer and quicker. With the advent of such
technologies, we seem to be geng closer to our long-standing desire to ablate
malignant pulmonary lesions in paents who cant tolerate surgical intervenons.
1. Rojas-Solano JR et al.; J Bronchology Interv Pulmonol. 2018 Jul;25(3):168-175.
2. Fielding D et al.; CHEST 2017 Oct; 152,( 4) Supplement A858 - Abstract of oral presentaon
Editorial Staff
Associate editor: Dr. Ali Musani
Associate editor: Dr. Sepmiu Murgu
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
101 College St., PMCRT 2-405
Toronto, Ontario M5G 1L7
Phone: 416-581-7486
E-mail: newsleer@wabip.com
P A G E 17
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
www.jrs.or.jp The Japanese Respirology Society
Asociación Sudamericana de Endoscopía Respiratoria
P A G E 18
When: February 8-10, 2019
Where: SGPGI, Lucknow, India
Program Director: Dr. AJMAL KHAN
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Hands-on workshop,
Conference (didacc lectures)
Website: hp://www.broncocon2019.com
Basic & Advanced Diagnosc Flexible Bronchoscopy Course
When: March 21-22, 2019
Where: Steigenberger Hotel -El Tahrir, Cairo
Program Director: Prof. Emad Korraa, MD
Program Type: Hands-on workshop, didacc lectures
8th Asian Pacic Congress on Bronchology and Intervenonal Pulmonology (APCB)
When: March 27-30, 2019
Where: Gold Coast Convenon and Exhibion Centre, Broadbeach QLD 4218, Australia
Program Director: David Fielding, M.D.
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hp://www.apcb2019.com
Advanced Diagnosc Bronchoscopy Workshop
When: March 29-30, 2019
Where: Eden Roc Hotel, Miami Beach Florida
Program Director: Atul C. Mehta, MD
Program Type: Hands-on workshop, didacc lectures
Website: hp://www.clevelandclinicmeded.com/live/courses/bronch/default.asp
60th Internaonal Conference of the Egypan Society of Chest Diseases and Tuberculosis
When: April 2-5, 2019
Where: Hilton Heliopolis Hotel, Cairo, Egypt
Program Director: Prof. Mohamed Awad Tageldin, Prof. Gehan Elassal
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Educaonal seminar
(for trainees only)
Conference (didacc lectures)
Website: hp://www.egyptsct.com
5th European Congress for Bronchology and Intervenonal Pulmonology (ECBIP)
When: May 8-11, 2019
Where: Dubrovnik, Croaa
President: Prof. Dr. Mihovil Roglić
Program Type: Conference (didacc lectures)
Website: hp://ecbip2019.eu
P A G E 19