Volume 09
Issue 02
May 2021
Inside This Issue
Editorial, 2-3
Technology Corner, 4-5
Tips from the Experts, 6-9
Humanitarian News, 10-14
Best Image Contest, 15
WABIP News, 16
Research, 17
Links, 18
Editorial: The Role of Liquid Biopsy in the
Management of Non-small Cell Carcinoma
WABIP Newsletter
M A Y 2 0 2 1 V O L U M E 9 , I S S U E 2
Hideo Saka, MD
Japan, Chair
Stefano Gasparini,
Italy, Vice-Chair
Silvia Quadrelli, MD
Argenna, Immediate
David Fielding MD
Australia, Treasurer
Naofumi Shinagawa,
Secretary General
Philippe Astoul, MD
France, President
WCBIP 2022
Menaldi Rasmin, MD
Indonesia, President
WCBIP 2024
Michael Mendoza
General Manager
Judy McConnell
Kazuhiro Yasufuku
Newsleer Editor-in-
P A G E 2
Peter B Illei, MD
Associate Professor of Pathology and Oncology
Department of Pathology
Johns Hopkins University School of Medicine
Lung cancer is the second most common cancer
type with an esmated 228,000 new cases and
135,700 death annually represenng nearly 13% of
all cancer diagnoses and 22% of all cancer death in
the United States
. Strategies to reduce lung cancer
death include prevenon by eliminang risk factors
(i.e. reduce smoking and other toxic inhalants like
radon), early detecon by developing screening
guidelines, and providing personalized therapy
both for locoregional and metastac disease.
Nearly 50% of all lung cancers are non-squamous
non-small cell carcinomas the majority of which
being adenocarcinomas. Approximately 60% of
these tumors are known to have a driver genec
alteraon. Personalized therapy requires accurate
histologic diagnosis and staging together with iden-
caon of targetable genec alteraons (EGFR,
ALK, ROS1, BRAF etc.) and predicve biomarkers
(PD-L1). Pathologic classicaon requires a ssue
or cytology sample and the gold standard for mo-
lecular studies is also ssue-based. Close to half
(49%) of non-small cell carcinomas are diagnosed
as advanced stage (IIIB or IV) disease and the diag-
nosis is typically is based on a biopsy of the primary
tumor or a metastasis
. This can result in small
samples containing insucient tumor for biomarker analysis.
This is parcularly true for hard-to-reach small lung nodules,
in the presence of marked necrosis and samples of meta-
stac mediasnal lymph nodes with minimal to low tumor
burden. Similarly, a subset of loco-regional disease is not
amenable to surgical intervenon and therefore needs a bi-
opsy to establish the diagnosis. Current NCCN guidelines re-
quire tesng for targetable alteraons with FDA-approved
therapy (EGFR, ALK, ROS1, BRAF, NTRK, METexon14) all non-
squamous non-small cell carcinomas, and squamous cell car-
cinomas of never or former light smokers. In addion, EGFR
mutaon tesng should be performed in stage IB-IIIA adeno-
carcinomas, and PD-L1 should be assessed in all non-small
cell carcinomas
. There is a need for an alternave tesng
method for paents who are not candidates for a biopsy or
whose biopsy resulted in insucient ssue for biomarkers.
Cell-free DNA (cfDNA) is a product of dying non-neoplasc
cells (mostly white blood cells) that can be detected in the
blood/plasma and other body uids as can be cell-free tumor
DNA (ctDNA) and exosome DNA. The amount of circulang
ctDNA is determined by the number of tumor cells shedding
into the bloodstream, which varies between tumor types and
tumor stage. Liquid biopsy is a test that examines the pres-
ence of ctDNA, circulang tumor cells, or exosome DNA in
various types of body uids (i.e. plasma, pleural uid, cere-
brospinal uid etc.). Liquid biopsy can be used to detect mu-
taons, translocaons, copy number alteraons, and allele
frequency at inial diagnosis, as well as when monitoring
disease recurrence or therapeuc responses. Several dier-
ent assay types are being used and they can be grouped
based on the number of genes targeted, namely as single
gene or mul-gene assay. Single gene assays use highly sensi-
ve PCR-based methods (i.e. real-me PCR, digital droplet
PCR), while most mul-gene assays use next-generaon se-
quencing (NGS). Single gene assays require more tumor DNA
and higher tumor content and can only detect mutaons that
are specically targeted by the assay. In contrast, NGS assays
P A G E 3
ents. The role of liquid biopsy with current approved methods in
early-stage disease is in the experimental phase and the sensivity
needs to be improved before widespread adaptaon can be done.
Future trends include improving sensivity and specicity of the
molecular assays, developing new methods that can detect epige-
nec changes of targetable alteraons, as well as tumor-specic
genome-wide DNA proles including epigenec (methylaon)
paerns using cfDNA as the source
. This approach could help
develop a blood-based screening tool for early detecon of tu-
mors, targetable alteraons and potenally provide prognosc
informaon regarding disease recurrence and therapeuc re-
1. Incidence of lung cancer. hps://seer.cancer.gov/staacts/html/
lungb.html#content (accessed 04/05/2021).
2. Heist RS et al. Cancer Cell. 2012; 21(3): 448.e2.
3. NCCN Clinical Pracce Guidelines in Oncology (NCCN Guidelines®) for
Non-Small Cell Lung Cancer V.4.2021. hps://
nccn_nsclc_guidelines.pdf (accessed 04/08/2021).
4. Cobas EGFR Mutaon test v2 FDA approval. hps://www.fda.gov/
v2 (accessed 4/20/2021).
5. FDA Approves First Liquid Biopsy Next-Generaon Sequencing Com-
panion Diagnosc Test. 4/20/2021. hps://www.fda.gov/news-events/
sequencing-companion-diagnosc-test (accessed 04/19/2021).
6. FoundaonOne Liquid CDx. 04/20/2021. hps://www.fda.gov/
p190032 (accessed 04/19/2021).
7. Aggarwal C et al. JAMA Oncol. 2019; 5(2): 173-80.
8. Chen Y et al. Neoplasma. 2019; 66(4): 652-60.
9. Zhang B et al. Lung Cancer. 2019; 134: 108-16.
10. D'Angelo SP et al. J Thorac Oncol. 2012; 7(12): 1815-22.
11. Jiang J et al. J Mol Diagn. 2020; 22(2): 228-35.
12. Liu Y et al. Transl Lung Cancer Res. 2021; 10(2): 914-25.
13. Satapathy S et al. Curr Probl Cancer. 2021: 100722.
14. Lee SE et al. Transl Lung Cancer Res. 2021; 10(1): 104-16.
15. Crisano S et al. Nature. 2019; 570(7761): 385-9.
require less DNA and lower tumor content, can detect un-
known mutaons (hybrid capture method), and work well
with fragmented DNA.
There are several FDA-approved liquid biopsy assays in ad-
vanced-stage lung cancer while there are no approved assays
for early-stage (loco-regional) disease. The FDA-approved
assays are the cobas® EGFR Mutaon Test v2 (single-gene
test, approved in June 2016)
, as well as the Guardant360
CDx and FoundaonOne Liquid CDx assays (both NGS based,
approved in August and November 2020, respecvely)
Liquid biopsy tesng is also performed using laboratory-
developed-validated assays. These liquid biopsy assays have
shown a good correlaon with matched ssue-based tesng
results (i.e. 81.3% concordance in a study of 128 tumors)
On the other hand, results in early-stage non-small cell lung
cancer have shown poor correlaon with ssue-based
even though the frequency of targetable driver
mutaons appears to be similar at diagnosis across all stages
(i.e. a study of lung adenocarcinoma showed that the preva-
lence of EGFR mutaons ranged between 22-26% in stage I-
IV tumors)
. A recent study of 197 tumors showed concord-
ance between matched plasma and ssue samples to be
12.4% in stage I, 58.3% in stage II, 55.6% in stage III, and
73.8% in stage IV disease
. The cause for this discrepancy is
likely due to dierences in tumor cell shedding, proliferave
acvity, and the extent of tumor necrosis.
Studies have also shown that liquid biopsy assays can iden-
fy circulang ctDNA in subclinical disease parcularly when
monitoring for disease progression or therapeuc eect.
Numerous studies have also been published demonstrang
that liquid biopsy can detect ctDNA in other body uids in-
cluding pleural uids, CSF (especially in cases with lep-
tomeningeal involvement), as well as uid-based specimen
preparaons like bronchoalveolar lavage or aspirate super-
Liquid biopsy is increasingly being used in clinical pracce
primarily in paents with stage IV disease who have no or
insucient tumor ssue for tesng. The availability and ease
of collecon of blood samples make plasma-based tesng
very aracve for oncologists, parcularly in high-risk pa-
Technology Corner
Cone beam CT Applicaons for Bronchoscopy
Cone beam CT (CBCT) imaging is a relavely new modality in intervenonal pulmonology, but is a frequently used technology sup-
porng intervenonal radiology and/or cardiovascular procedures. As such, it is oen a readily available system in most centers. It
is furthermore likely that these systems have considerable downme [1] as only one or two speciales are performing specialized
procedures using the CBCT which, in some instuons, oers the opportunity for the intervenonal pulmonologists to use it.
The term cone beam CT refers to the fact that the systems allow for a 3D X-ray projecon by rotang a C-arm with a cone-like di-
verging X-ray beam around the paent in several seconds. This is dierent than that of convenonal CT, where it is foremostly a
narrow fan-like beam of X-rays rotated in helical fashion around the paent with high speed. While this gives addional challenges
from a technological perspecve, it allows for unique addional features too. The xed C-arm of the CBCT arm leaves a lot of open
space as working area and is registered with the table on which the paent is posioned. Once an inial CBCT scan has given 3D
informaon, a digital work staon in the room can subsequently be used to segment certain regions of interest or pathways there-
to. Aer segmentaon, subsequent normal uoroscopy2D imaging within the room is enhanced with the projecon of the seg-
mented volume and/or pathway. This overlay, called augmented uoroscopy (AF), is then accurately maintained in 3D during every
movement of the C-arm and table, and can be used to navigate towards the lesion.
Clinical applicaon
When aempng to biopsy small peripheral nodules, cone beam CT guided navigaon can be used to navigate towards, and subse-
quently biopsy the target lesion. Although mulple dierent modalies are available for navigaon, cone beam CT systems oers
addional value since it can accurately conrm target access in 3D. This conrmaon is vital for opmal diagnosc sampling, deliv-
er markers, and local therapeuc procedures.
How we do it
Our current navigaon bronchoscopy program is based upon the therapeuc bronchoscope and catheters in combinaon with
CBCT and rEBUS under general anesthesia. Aer an inial inspecon bronchoscopy, commercially available steerable navigaon
catheters (e.g. from electromagnec navigaon systems) are inserted. Aer inspecon, a rst quick aempt is made to insert the
catheter according to the pathway as memorized on pre-procedural CT. The scope is xated above the paent. The radiaon tech-
nician checks if a full collision free C-arm rotaon can be made. Everyone leaves the room and an inial 3D CBCT acquision is
made in breath-hold. Both the target nodule and the route toward this nodule are segmented and overlayed as augmented uor-
oscopy imaging (AF) on the dedicated workstaon. For enabling navigaon, small dotsare placed at the bifurcaons along the
route to highlight the route and addionally show where correct angulaon is most important (Figure 1). Subsequent augmented
P A G E 4
Erik van der Heijden, MD
Associate Professor
Radboud University
Medical Center
Nijmegen, The
Stephan Kops, MD
Radboud University
Medical Center
Nijmegen, The
Roel Verhoeven, MSc
Technical Medicine
Radboud University
Medical Center
Nijmegen, The
uoroscopy imaging can now be performed with dierent C-arm angulaons, having the overlayed route and lesion to conrm reposion-
ing or progression. When the target lesion is close, radial EBUS miniprobes and 3D-image conrmaon with a new CBCT acquision are
used to conrm lesion access. If needed, reposioning is performed under addional image guidance. Aer lesion access conrmaon, s-
sue sampling is repeatedly performed under guidance of AF and repeated rEBUS. Sampling is performed under AF at mulple angulaons
and small, constant adjustments of the catheter rotaon and posion.
We frequently perform 2 CBCT scans (of dierent dose) per lesion. Depending on system sengs, paent characteriscs and the amount of
collimaon used, an inial high qualityCBCT acquision will result in a paent dose of approximately 2-4 mSv. Total procedural
(augmented) uoroscopy dose is highly dependent on how specic and sparsely it is used. As an example, at the start of our program the
procedural uoroscopy paent dose was 5.2 mSv (592 seconds). In an experienced seng (i.e >100 procedures), we however reduced to a
mean of 0.37 mSv per procedure (935 seconds). Knowing the sta should leave the room during CBCT acquision and wear adequate pro-
tecon and systemacally put a mobile safety screen in between themselves and the c-arm, the sta dose seems to be of a lesser concern.
Several studies have reported on their accuracy ndings when using CBCT in addion with other guidance techniques, reaching diagnosc
yields of 70-84% [2]. Combining above menoned workup with EMN in approximately half of procedures, our inial report found an overall
diagnosc accuracy of 72% in 87 paents [3]. Importantly however, analysis of our program aer having performed more than 150 proce-
dures shows the changing performance over me. In a more recent series (Nov 2019 June 2020) of 64 paents, an accurate diagnosis
without changing inclusion criteria could be obtained in some 90% of paents [4]. This is a signicant improvement over our own and other
previously reported accuracies with commercially available technology. However, our analysis of more than 200 consecuvely CBCT guided
navigaon bronchoscopy cases also shows that there is an important learning curve to overcome [3, 4].
Cone beam CT guided navigaon bronchoscopy is a valuable opon to navigate to, and obtain a ssue diagnosis in small, peripheral pulmo-
nary nodules, and is likely a prerequisite to precisely deliver minimal invasive treatments. The limited data available seem to imply it has
the potenal of a high diagnosc accuracy, outperforming other technologies, but it is important to note there is a signicant learning
curve to overcome. The radiaon dose needed is (relavely) low. Further research is warranted to improve the intuivenessto use this
guidance tool as well as improvement of our sampling tools to reduce procedure me.
W A B I P N E W S L E T T E R P A G E 5
1. Patel S et al. Int J Health Policy Manag, 2020.
2. Casal R.F. J Bronchology Interv Pulmonol, 2018. 25(4): p. 255-256.
3. Verhoeven R.L.J et al. J Bronchology Interv Pulmonol, 2021. 28(1):
p. 60-69.
4. Verhoeven R.L.J et al. Cone-beam CT and augmented uoroscopy
guided navigaon bronchoscopy; radiaon exposure and diagnosc
accuracy learning curves. Submied, 2021.
Figure 1:
On the le: CBCT-based navigaon bronchoscopy in pro-
gress. On the right, top: two images of the workstaon for
segmentaon. On the right, boom: augmented uoroscopy
image of the extended working channel with the radial EBUS
miniprobe being inserted into the target lesion (in blue-
green). The red dots indicate the navigaon route.
Tips from the Experts
P A G E 6 V O L U M E 9 , I S S U E 2
More than 50% of paents with malignant pleural eusion (MPE) reaccumulate uid aer the inial drainage, with up to 30% of paents
developing rapid re-accumulaon within two weeks [1,2]. Guidelines from professional sociees recommend that paents who are sympto-
mac with recurrent suspected or known MPE should undergo denive pleural intervenons [3-5]. These intervenons include talc pleu-
rodesis with or without thoracoscopy, and tunneled indwelling pleural catheter (TIPC) placement. These procedures result in fewer subse-
quent pleural procedures and complicaons such as pneumothorax and complex pleural space [1]. Despite the high incidence of MPE,
guideline consistent care of providing denive pleural intervenon is followed in less than 25% of paents [1]. Here, we aim to provide a
raonale for selecng the appropriate denive pleural intervenon for managing paents with recurrent MPE.
Indicaons, planning and techniques for specic pleural intervenons
1. Talc Pleurodesis with Insuaon or Slurry
In paents with recurrent symptomac MPE who experience relief of their dyspnea with uid drainage and have a complete or parally ex-
pandable lung, achieving pleurodesis can minimize pleural uid reaccumulaon. This can be achieved via chemical pleurodesis by inslling a
sclerosant, such as talc, into the pleural space. Talc pleurodesis can be performed by inslling talc slurry via a chest tube or by insuaon
during thoracoscopy by applying a spray atomizer. This can be performed using a dedicated catheter either through the trocar adjacent to
the rigid pleuroscope or a catheter inserted through the working channel of a semi-rigid pleuroscope. In both cases, talc insuaon can be
applied under direct visualizaon, maximizing the distribuon of the talc on the desired surfaces, which should include normal parietal pleu-
ra (Figures 1A,1B).
There is mixed data regarding the opmal method for talc delivery. Several randomized trials, systemac reviews, and meta-analysis suggest
no overall dierence between thoracoscopic talc insuaon and bedside talc slurry via chest tube in regard to pleurodesis success, compli-
caons, clinical outcome, or recurrence of pleural eusion [6-10]. That being said, pleurodesis success rate using thoracoscopic talc insua-
on for MPE has been reported as high as 77-98% [11-16]. One systemac review suggested that talc insuaon was associated with less
risk of recurrence than talc slurry via chest tube [17]. In addion, in a post-hoc analysis, Dresler et al. showed that paents with primary lung
or breast cancer were noted to have higher rate of pleurodesis with talc insuaon compared to talc slurry via chest tube (82% vs 67%) [8].
Terra et al. noted that immediate paral lung expansion was more frequently seen in paents who received thoracoscopy with talc insua-
on as opposed to talc slurry via chest tube (60% vs 30%) [9]. Whether this translates to improved clinical outcomes is unclear.
The decision to proceed with either talc insuaon or talc slurry depends on the local resources, operator experience, paent risk factors,
and paent values. In our instuon, paents with relavely good performance status (ECOG 0-2) and someme ECOG 3, are oered both
Indwelling Catheters and Pleurodesis for Managing Recurrent Malignant Pleural
Sepmiu Murgu, MD
The University of Chicago
Elliot Ho, DO
The University of Chicago
Tips from the Experts
P A G E 7 V O L U M E 9 , I S S U E 2
thoracoscopic talc insuaon and TIPC. Paents with poor performance status (ECOG 3-4) at high risk for anesthesia, are usually managed
with TIPC. We do not rounely place a chest tube for talc slurry in these paents, but if paents already have an indwelling chest tube, then
talc slurry via the exisng chest tube is performed.
2. Tunneled Indwelling Pleural Catheter Placement
While paral or complete re-expandable lung is needed for chemical pleurodesis, TIPC placement is the treatment of choice for paents with
non-expandable lung, or those who failed chemical pleurodesis. This is relevant, especially since some data suggest that approximately 30%
of paents with MPE have non-expandable lung [8]. The major disadvantages are the need for frequent drainage (someme considered by
paents an intervenon per se), the need for clinic appointments to troubleshoot catheter occlusion and management of catheter-related
skin infecon, as well as lifestyle modicaons that have to account for me to drain the catheter on a regular basis (every day per some pro-
tocols) and avoiding soaking the catheter in water (e.g. pool, bathtub). Regardless of lung expandability, several guidelines suggest that TIPC
placement is just as eecve as talc pleurodesis in relieving symptoms of dyspnea and improving quality of life in paents with recurrent MPE
[2-4]. Two landmark studies (TIME2 and AMPLE) showed no dierence in the relief of dyspnea between TIPC placement and talc pleurodesis,
however showed reduced length of hospital stay and need for subsequent pleural procedures in paents who received TIPC placement
TIPC can be placed either under local anesthesia at the bedside (or procedure suite) with ultrasound guidance or via thoracoscopy under di-
rect visualizaon (Figures 1C,1D). In both cases, the indwelling catheter should be guided towards the diaphragmac recess to facilitate com-
plete evacuaon of the pleural uid. Although pleurodesis is not necessarily the goal for TIPC placement, spontaneous pleurodesis has been
reported in 30-58% of paents who undergo TIPC placement [19-23]. This may be the result of keeping the pleural space dry with daily drain-
age allowing for approximaon of the pleural surfaces, and the inammatory response caused by the presence of the indwelling catheter in
the pleural space. We have also noted spontaneous pleurodesis in some paents with non-expandable lung on inial evaluaon. This may be
due to shiing of thoracic structures within the chest cavity (ipsilateral mediasnal shi, elevaon of the hemidiaphragm) as a result of daily
drainage of pleural uid resulng in the approximaon of pleural surfaces, lack of drainage, and subsequent catheter removal.
In our opinion, a meaningful dialogue with paents and their caregivers is in order prior to inserng a TIPC that may be needed for months
(median me to TIPC removal: 44-90 days), if not for the rest of the paents life [20,24]. Correct expectaons should be set in regard to fre-
quency of drainage, chance of catheter removal, possibility of uid recurrence aer catheter removal (4-14%) [24], and potenal TIPC-related
complicaons and their management (including occlusion and infecon).
3. Thoracoscopy: Stand Alone, with TIPC Placement, Talc Insuaon or a Mulmodal Approach
Thoracoscopy can be performed either under moderate sedaon or general anesthesia. In our pracce, thoracoscopy is performed in the
operang room with the paent under general anesthesia. Double lumen intubaon is used to permit single lung venlaon during the pro-
cedure. This allows for deaon and isolaon of the target pleural space, giving the operator maximal pleural cavity to work with during the
procedure. We rounely use ultrasound guidance not only to conrm that the lung has been properly isolated (US reveals pneumothorax
paern at the desired point of entry), but also to dene the complexity of the pleural space, which may predict the need for a more complex
intervenon, rather than a single port thoracoscopy. Once the trocar is inserted, either rigid or semi-rigid pleuroscope is used for drainage,
exploraon of the pleural cavity, and to obtain pleural biopsies, if needed for ssue diagnosis or ancillary studies (molecular tesng, PD-L1
tesng, etc.).
Even though thoracoscopy is oen used in conjuncon with either TIPC placement or talc pleurodesis, the ability to induce pleurodesis may
also be intrinsic to thoracoscopy. Suzuki et al. noted that spontaneous pleurodesis occurred in 53% of paents who underwent thoracoscopic
placement of TIPC as compared with 28% of paents who underwent TIPC placement via standard technique [25]. Another study demon-
strated spontaneous pleurodesis rate of 58% in paents with trapped lung undergoing TIPC placement via thoracoscopy [26]. This may be the
result of completely drying out the pleural space under direct visualizaon, mechanical irritaon of the pleural space from thoracoscopy inci-
sion and pleural biopsies leading to an inammatory response, and the ability to perform adhesiolysis in paents with loculated eusions.
There is increasing interest in combining the use of TIPC placement with talc insuaon in paents undergoing thoracoscopy during the
same procedure in order to improve the likelihood of pleurodesis and reduce the me to catheter removal. We rounely apply this approach.
We believe that in addion to the intrinsic ability of thoracoscopy to induce pleurodesis, direct visualizaon under thoracoscopy allows for
directed applicaon of talc insuaon across the pleural surfaces and guidance of the TIPC placement towards the diaphragmac recess. The
data supporng this pracce is limited, but emerging. In a pilot study, the combinaon of thoracoscopy with talc insuaon and TIPC place-
Tips from the Experts
P A G E 8 V O L U M E 9 , I S S U E 2
ment in the same procedure resulted in high pleurodesis success of 92% and early TIPC removal, with median duraon of TIPC of 7.54 days
post-intervenon, and median length of hospital stay of 1.79 days [27]. Similarly, in a prospecve observaonal study, the combinaon of
thoracoscopy with talc pleurodesis and TIPC placement also resulted in high pleurodesis success of 92% at 1 month, 96% at 6 months, and
early TIPC removal, with median duraon of TIPC of 6 days post-intervenon, and median length of hospital stay of 3 days [28]. Therefore, we
believe that when discussing with paents the opons for more denive pleural intervenons for their recurrent and symptomac MPE, it is
important to assess their values and evaluate whether the benets of early TIPC removal seen with thoracoscopic TIPC placement, outweighs
the risks of thoracoscopy and the costs of post-procedural hospitalizaon. In addion, hospitalizaon is not always necessary; in fact, some
operators apply a rapid pleurodesis protocol, which involves discharging paents 24-hours aer combined thoracoscopy with TIPC placement
and talc pleurodesis, with connued home TIPC drainage [27]. In paents with concurrent need for pleural biopsies, complex pleural eu-
sions, or unwillingness to have a long-term TIPC, a mulmodal approach should be considered given the possibility for early TIPC removal.
Quality Control: Post-procedural Management
TIPC placement with local anesthesia can be performed on an outpaent basis and does not require hospitalizaon. However, with thoraco-
scopic TIPC placement and talc pleurodesis, there is a subsequent increased inammatory response in the pleural space usually leading to
pain and increased pleural drainage. In our pracce, in addion to the TIPC, a 24-28Fr chest tube is placed during thoracoscopy in order to
allow for connuous drainage to keep the pleural space as dry as possible to opmize the eects of talc pleurodesis. We typically keep pa-
ents hospitalized for 1-3 days unl the pleural uid drainage is minimal (<100-150 cc) and to allow for opmizing pain control and connu-
ous pleural drainage [29]. An alternave approach, using rapid pleurodesis concept, involves discharging paents 24-hours aer combined
thoracoscopy with TIPC placement and talc pleurodesis, with connued home TIPC drainage (three mes daily on post-op day 1, two mes
daily on post-op day 2-3, and then daily) [27]. Randomized trials have not been performed comparing the two approaches in regard to pleu-
rodesis success, symptomac improvement and need for repeat intervenons.
Drainage Protocol
The ASAP and AMPLE2 trials evaluated daily TIPC drainage as compared with alternate day drainage and symptom-based drainage, respec-
vely, and demonstrated higher rates of spontaneous pleurodesis in paents who drained daily [20,21]. Although, there was no signicant
dierence in dyspnea control between the two groups, the higher rates of spontaneous pleurodesis in paents who drained daily may trans-
late to early TIPC removal. In our pracce, we recommend daily drainage unl drainage is less than 150 cc daily on three occasions, which is
then extended to every other day drainage. Once drainage is less than 150 cc on three occasions, drainage is extended to every three days. If
drainage is sll less than 150 cc on three occasions, we evaluate paents at that me for TIPC removal.
Post-procedural care is oen instuonal and resource dependent. At our instuon, we evaluate paents in clinic two weeks aer the pro-
cedure or sooner if needed with repeat chest imaging and suture removal on the day of clinic visit. There is emerging evidence that TIPC re-
moval is someme performed at the me of disease control, not because of pleurodesis. In fact, we rounely perform thoracic US at the me
of TIPC removal with the intent to predict which paents are more likely to recur aer catheter removal based on sonographic ndings of
lung sliding or to document possible pleurodesis by visualizing the lack of lung sliding [24].
Pleural intervenons for palliang symptoms due to MPE are recommended for paents with recurrent symptomac MPE who experience
relief of their dyspnea with uid drainage. Decision to select the appropriate intervenon should be individualized based on local resources,
operator experience, paents comorbidies, funconal status, and values. A mulmodal approach including thoracoscopy with talc pleu-
rodesis and TIPC placement as a more denive pleural management may fasten the me to pleurodesis, allowing for early TIPC removal.
Tips from the Experts
P A G E 9 V O L U M E 9 , I S S U E 2
1. Ost DE et al. Chest. 2018 Feb;153(2):438-452.
2. Grosu HB et al. Respirology. 2019 Jan;24(1):76-82.
3. Feller-Kopman DJ et al. Am J Respir Crit Care Med. 2018 Oct 1;198(7):839-849.
4. Bibby AC et al. Eur Respir J. 2018 Jul 27;52(1):1800349.
5. Planchard D et al. Ann Oncol. 2019 May;30(5):863-870.
6. Yim AP et al. Ann Thorac Surg. 1996 Dec;62(6):1655-8.
7. Mummadi S et al. F1000Res. 2014 Oct 27;3:254.
8. Dresler CM et al. Chest. 2005 Mar;127(3):909-15.
9. Terra RM et al. Chest. 2009 Aug;136(2):361-368.
10. Bhatnagar R et al. JAMA. 2019 Dec 5;323(1):609.
11. Janssen JP et al. Lancet. 2007 May 5;369(9572):1535-1539.
12. Viallat JR et al. Chest. 1996 Dec;110(6):1387-93.
13. de Campos JR et al. Chest. 2001 Mar;119(3):801-6.
14. Kolschmann S et al. Chest. 2005 Sep;128(3):1431-5.
15. Steger V et al. Ann Thorac Surg. 2007 Jun;83(6):1940-5.
16. Barbetakis N et al. J Cardiothorac Surg. 2010 Apr 19;5:27.
17. Tan C et al. Eur J Cardiothorac Surg. 2006 May;29(5):829-38.
18. Davies HE et al. JAMA. 2012 Jun 13;307(22):2383-9.
19. Thomas R et al. JAMA. 2017 Nov 21;318(19):1903-1912.
20. Wahidi MM et al. Am J Respir Crit Care Med. 2017 Apr 15;195(8):1050-1057.
21. Muruganandan S et al. Lancet Respir Med. 2018 Sep;6(9):671-680.
22. Tremblay A et al. Chest. 2006 Feb;129(2):362-368.
23. Warren WH et al. Ann Thorac Surg. 2008 Mar;85(3):1049-55.
24. Chaddha U et al. Respirology. 2021 Mar;26(3):249-254.
25. Suzuki K et al. J Thorac Oncol. 2011 Apr;6(4):762-7.
26. Schneider T et al. Thorac Cardiovasc Surg. 2009 Feb;57(1):42-6.
27. Reddy C et al. Chest. 2011 Jun;139(6):1419-1423.
28. Boujaoude Z et al. J Bronchology Interv Pulmonol. 2015 Jul;22(3):237-43.
29. Lee P et al. Respirology. 2007 Nov;12(6):881-6.
Figure 1: (A) Talc insuaon applied with thoraco-
scopic guidance. (B) Talc powder is distributed homog-
enously over the parietal pleura. (C) Dilator and guide-
wire are oriented towards the diaphragmac recess
during TIPC placement under direct visualizaon. (D)
Successful TIPC placement with thoracoscopic guid-
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W A B I P N E W S L E T T E R P A G E 10
Ethical Issues of Immunity Passports
Since the beginning of the pandemic, strict lockdown measures have been imposed in most of the countries in order to re-
duce the spread of the coronavirus. Social distancing, home working, only virtual acvies for school, university and academ-
ic convenons were implemented in dierent mes and with dierent length as well as mask wearing and home quarann-
ing. Some of these measures had very signicant social and economic costs, mainly by prevenng many people from work-
ing. The main reason that has obliged to lockdown measures (increasingly unpopular because of their economic impact) is
the potenal for asymptomac infecon and spreading of COVID-19. People who do not experience symptoms when infect-
ed with COVID-19 is esmated to be around 40% and there is evidence that support the hypothesis that a large proporon
of the transmission of the virus occurs before the onset of symptoms, making necessary to have ways of prevenng of
spreading of the disease from asymptomac persons.
Most of governments do not consider mandatory vaccinaon as an acceptable strategy. But more recently, taking into ac-
count the new waves, new variants, increasing pressures to return to free circulaon of people, many governments are con-
sidering some sort of immunity passports. Those cercates would allow people with proof of immunity (because of having
suered the disease and/or having received full vaccinaon) to have more freedom of circulaon. But those proposals raise
many logiscal and ethical concerns as people without that cercaon will be excluded from everyday life.
The main purpose of vaccine passports is to allow people to travel, aend large gatherings, access public venues, and return
to work without compromising personal safety and public health. The UK government recently announced that it is being
analysed whether Britons will need a vaccinaon test or a negave Covid-19 test to visit bars, return to the oce, or aend
theaters and sporng events. Dierent countries are considering dierent acvies that would be permied for holders of
those immunity passports but not to other people.
In Israel, a vaccine passport allows those vaccinated to go to hotels and gyms while Iceland is distribung vaccine passports
to facilitate travel abroad for the vaccinated. In the US government, some agencies are evaluang the feasibility of creang
digital Covid-19 vaccinaon cercates. New Yorks Excelsior Passpermits aendance at theaters, arenas, event venues,
and large weddings and European Union plans a Digital Green Cercatethat would allow free travel within the EU
Beyond dierent government intenons, it is prey certain that proof of vaccinaon against COVID-19 may soon be a re-
quirement for airline or cruise ship passengers. Some companies—like Qantas Airlines and the American Queen Steamboat
Company—have announced that they will soon require immunity passports,” to use their services and some employers may
soon mandate vaccinaons as well.
Many tech companies, are working around the clock to provide the technology required for digital immunity passports, pre-
dicng that they will be widely used in the near future and many countries see they will need to develop those passport if
they are requested by other countries in order to be able to ensure alignment with global standards.
But in spite of this rapid progress to the acceptability of the idea of the implementaon of those cercates, there are sll
many scienc challenges and the discussion about if they are lawful and ethical Is not closed yet.
Immunity passports would a way to go back to a more normal social and economic life, but their potenal benets will be
unequally distributed, giving rise to doubt about how ethical their implementaon will be.
On the one hand, immunity passports oer an opportunity for employees to go back to work and families to reunite. On the
other hand, they will not be available to everyone, and they will exacerbate exisng inequalies.
An inial disncon should be established between immunity passports(those given to those who have suered the dis-
ease and have proof of circulang anbodies) and the vaccinaon passports(applied only to those who have received a
full vaccinaon).
As the COVID-19 pandemic progresses, many people worldwide will contract the virus and recover. Many of these will be
asymptomac or experience mild symptoms only. Whether all illness results in sucient levels of neutralising anbodies to
prevent against reinfecon is sll under invesgaon. Although experience with diseases like severe acute respiratory syn-
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W A B I P N E W S L E T T E R P A G E 11
drome (SARS) and Middle East respiratory syndrome (MERS) suggests that anbody responses are likely to persist for at least
a year it is not fully established yet what level of immunity is conferred by infecon. It is reasonable (although not proved) to
believe that people who have been infected and subsequently recovered are likely to be at least temporarily at lower risk of
reinfecon or severe disease and less likely to spread the virus to other people. But the extent and duraon of immunity
infecon from COVID-19 is uncertain and the WHO has repeatedly stated that there is no evidence of lasng immunity in
those recovered from COVID-19. In fact that evidence would be to wait very long aer infecon and test the immunity in
recovered paents to conrm the prevalence of anbodies at 1, 5, 10 or more years.
If anbody responses to COVID as in SARS and MERS are waned aer 23 years, immune passports should be me limited. A
signicant limitaon on the introducon of immunity passports is the need for a suciently reliable rapid test for COVID-19
anbodies. Anbody, or serology, tests idenfy whether someone has developed anbodies to COVID-19. Assuming that
anbodies do indicate solid immunity, the challenge lies in correctly idenfying those anbodies in a way that permits
tesng to be scaled up signicantly, without exceeding a tolerable level of false posives/negaves.
Dierent tests vary in their accuracy and the quality of the evidence we have about their accuracy. The sensivity of tests in
the rst week or two aer infecon may be low. An addional problem is that the numbers of false posive and false nega-
ve tests (and so the impact those errors have) will depend on the baseline rates of infecon. If the rates of seroposivity
are low, many of those idened as being immune will be false posives. On the other hand, anbodies might not be iden-
able in blood tests unl days or weeks aer illness has resolved, resulng in a delay between an individual being infected
with COVID-19 and being tested seroposive.
Widespread anbody tesng could facilitate a faster return to a more normal way of life for at least some of the populaon.
But it could also create new pressures to intrude on peoples privacy and free choice. Employers may want all their employ-
ees to undergo tesng creang pressure on people into tesng in this manner.
The feasibility of being tested (and consequently have the possibility of having proof of immunity) requires the consideraon
of who should be priorized for tesng, not only taking into account the cost and logisc burden of over tesng but also the
need to avoid harmful misdiagnoses. It is likely that tesng will be priorized to healthcare sta and other key workers as
care home sta, police, supermarket sta, transport workers and some others that need to keep on working to permit social
funconing. It means that those populaons would receive the privilege of having access to tests and consequently proof of
immunity. It would not necessarily be unfair. The public good that those workers mean if they are allowed to move around
more freely, juses their posion of privilege for anbody tesng and immunity passports. But if immunity passports were
to be introduced, it is unclear how other groups should be priorized relave to one another to not create an unfair inequali-
ty of access to restricted acvies as it is likely that possessing an immunity passport would be a signicant benet, ad-
vantaging holders relave to non-holders.
As fairness requires all people to be treated the same in a strict sense, this would indeed be the case. But it is also true that
such a simplisc model of fairness is not appropriate in the current extraordinary condions and that privileging fairness
above other values (such as benets to individual well-being and economic recovery) is not necessarily a moral imperave.
The more people that are able to return to some of their normal funconing, the beer for society as a whole. On the other
hand, there is a risk of resentment from those unable to work or socialize due to their connued suscepbility. This could
result in a reducon in social cohesion and a loss of support of restricon measures, which could have a negave impact in
the longer term management of the pandemic. There might also be some concerns that those most likely to acquire immuni-
ty (and thus, immunity passports) are those who have been least responsible in following government guidelines while
those who strictly respected social distancing are the least likely to acquire immunity and immunity passports. It would
mean that immunity passports could reward the least responsible or even incenvize incauous behavior (as intenonal
exposure to the virus), in order to acquire an immunity passport legimately. It would undermine the eorts of containing
spread of the virus.
Successfully avoid geng COVID-19 should be enough advantage for those who behave conscienously, but it would sll be
unfair. To avoid that, governments should withhold immunity passports from those who acquire immunity through reckless
behaviour. It would require public educaon campaigns that make people aware that if they are caught violang the rules,
they will be ineligible for immunity passports. But, it will be dicult to determine retrospecvely whether an individual with
immunity acquired it through incauous behavior or not.
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W A B I P N E W S L E T T E R P A G E 12
In order to prevent the creaon of fraudulent immunity passports, systems of vericaon will be needed. A higher invest-
ment in technology would be necessary for the passports be harder to forge and punishments should be applied for those
involved in the black market of passports. All that machinery would largely decrease the economic benets of immunity
Taking into account all the challenging issues, especially the many ethical quesons but mainly the enormous scienc un-
certainty to support the use of immunity cercaon for those having suered the disease and showing proof of having an-
bodies, have not been widely accepted.
But with the availability of vaccinaon the idea of using cercaon of immunity, but restricted to immunity conferred by
vaccines, has re-emerged with force, as there is more scienc evidence for immunity from vaccines than from natural im-
However, even when the scienc foundaons are stronger and some logisc issues are easier to resolve, vaccinaon pass-
ports sll have their own ethical challenges. It could discriminate against minority communies, against people less eligible
or less likely to accept the vaccines, against those less likely to be given priority to receive them. And of course, globally
against people residing in countries with less access to vaccines. There are also big quesons about the ethics of granng
businesses access to peopleshealth records. In the current world of media technology corporaons the risk of big compa-
nies having access to private informaon and commercialize it or merge it with other informaon and then use it for their
advantage, is a concrete and real threat.
The project turns vaccinaon, if not mandatory, into almost compulsory in order to access to highly desirable acvies. For
instance, while vaccinaon in Israel is not mandated, parliament passed a law that would allow the Ministry of Health to
idenfy unvaccinated people and nofy them to the authories.
Because of the discriminaon that the cercates potenally impose, some opinions queson if those passports are even
Proof of immunizaon is far from being a new idea; during campaigns for the smallpox vaccine, the vaccine scar oen served
as this proof and gave access to acvies as train travel. Many countries require proof of immunizaon for school entry and
in most of the countries health care workers are required to present proof of vaccinaon against hepas B. The Equal Em-
ployment Opportunity Commission in the US allows employers to require SARS-CoV-2 vaccinaon to return to the work-
place, thus ensuring employees do not pose a direct threat to health or safety. If employees are not required to provide any
medical addional informaon as part of the proof, employers could require vaccinaon passports as proof their sta have
received a COVID-19 vaccinaon.
In fact, vaccine passports are not only permissible under internaonal health regulaons, but also they already exist. The
World Health Organizaon endorses cercates conrming vaccinaon against yellow fever for entry into countries where
the disease is endemic. Governments have power to validate and monitor vaccinaon status while requiring proof of vac-
cinaon for access to certain privileges. Internaonal law poses few restricons on vaccinaon cercaons. The Interna-
onal Health Regulaons, signed by 196 countries, grant wide discreon to exercise evidence-based public health powers. It
is the Arcle 31 of these regulaons which specically allows governments to require proof of vaccinaon or other prophy-
laxis,while Annex 7 authorizes yellow fever vaccinaon cercates for internaonal travel.
Opposite to immunity passports, which has the risk of incenvizing infecon, vaccine passports incenvize vaccinaon,
which is a posive benet and contributes to the whole populaon immunity.
It is also in accordance with the public health principle of least infringement that dictates that policy makers should imple-
ment the opon that least impairs individual liberes in order to achieve a common good. Lockdowns may be required in
order to decrease the number of cases and deaths, even when it is one of the major restricon of the civil liberes. Vaccine
passports could provide more freedom of movements for those with minimal risk of geng and spreading the disease and
help prevent other health and socioeconomic harms caused by lockdowns.
Ethical concerns about these passports are not resolved at all. The Nueld Council on Bioethics states that such passports
could enable coercive and sgmazing workplaces. Vaccine passports should be available and accessible to all countries and
to all populaons in each country. Otherwise they risk to increase the already exisng societal inequalies and worsening
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W A B I P N E W S L E T T E R P A G E 13
the health inequality. But that is not and easily achievable goal. Vaccines are scarce and access remains deeply unequal, both
globally and within countries. People facing vaccinaon access problems will be unable to obtain vaccine passports.
Even with a more fair access to vaccines, some groups are excluded from vaccinaon for medical reasons, cultural beliefs or
religious convicons.Covid-19 vaccines are contraindicated in some people with serious health condions and allergies and
pregnant women do not have evidence (as clinical trials did not include pregnant women) about the safety of vaccinaon
and may choose not to take that risk. In some countries, ethnic minories are also more likely to be vaccine hesitant, poli-
cal inclinaons may determine higher distrust in the vaccines and younger people, not being a priorized group, will take
much longer to be vaccinated as well as believing less vulnerable to severe disease, may be less inclined to get the vaccines.
But the most obscene inequality is that most vaccine doses are being delivered in high income countries, WHO warned that
the world is facing a catastrophic moral failure represented by the insucient eorts to support globally coordinated access
to covid-19 vaccines. It is esmated that nearly 25% of the worlds populaon will not have access to any COVID vaccine unl
2022, resulng in thousands of preventable deaths in less developed countries. Far from the inial dream that this global
crisis would improve the understanding of the urgent need of decreasing the unacceptable inequity between poor and rich
countries and poor and rich individuals, in most of the countries the pandemic is widening those dierences. Requiring proof
of vaccinaon mainly to be able to travel, will deepen the inequality and exclusion of the low income countries compared to
the high income countries.
Only when everyone can gain access to vaccines, there would be a strong ethical juscaon for vaccine passports in order
to create safer environments to work, shop, socialize, and travel, that could be preferable as a less restricve alternave to
lockdown measures. It means that if wanng to enjoy the potenal benets of vaccine passports without paying an unac-
ceptable moral price of unfairness and discriminaon, every country should contribute to the global eort in order to in-
crease access to vaccinaon, both globally and within countries. By denion, a pandemic is a global problem and must be
faced globally. Beyond any ethical concern, a world with less than half of the worlds populaon vaccinated will not be safe
for anyone.
If vaccines are fully and equally available to all members of society, including the most disadvantaged people, and in that
way, not taking the vaccine is a personal choice, it would be possible to argue that unvaccinated individuals have no right to
impose risks on others, thus impeding a return to normal acvies. Requiring people who decline vaccinaon to bear some
consequence for their refusal seems only fair, especially if, collecvely, such hesitancy puts herd immunity out of reach. In
that scenario, individuals who cannot be vaccinated for medical reasons should not be excluded from passport privileges and
granng exempons for genuine religious or conscienous objecons should be considered.
In the same way that the previously planned immunity passports, technical challenges are not resolved. Mechanisms for
reliable and accurate cercaon are important. The development of such mechanisms is a technical issue that sooner than
later some leading technology companies should be able to answer successfully. As vaccine passports would probably be
digital and require access to private medical records, there are important quesons around internet access, costs of acquir-
ing and maintaining the passports, privacy, and data protecon that must be carefully studied. In some countries a large pro-
poron of the populaon do not have smartphones or stable internet connecons and their exclusion would breach their
rights to equality. Allowing workplaces, airlines, and entertainment and leisure venues to access to vaccinaon data remains
controversial as it may permit paent sensive data be used for other purposes than the vaccine passports. It could also al-
low immunizaon informaon to be used by private companies like airlines, workplaces or amusement parks to deny entry
with the excuse of keeping people safe and liming the spread of this deadly virus. That would create an addional form of
elism and a deeper societal gap.
A key component of any internaonally valid passport should be that those cercaons need to be internaonally stand-
ardised and must have veriable credenals that prevent problems such as forgery and loss of privacy. Soware, implement-
ed in a standardized fashion, will be required to verify vaccinaon status and to determine whether immunizaon passports
meet current requirements for entry or access. Mechanisms must also exist to revoke passports if, for example, data emerge
that new variants of SARS-CoV-2 are resistant to vaccines. Technological development should occur in concert with legal and
ethical review to ensure that the soluon is the least restricve means of reopening society, without adversely aecng pop-
ulaons that are already marginalized. WHO has iniated a Smart Vaccinaon Cercate Working Group to establish key
specicaons and standards for eecve and interoperable digital soluons for covid-19 vaccinaon. Some instuons have
developed potenal criteria for such passports, for instance, the Royal Society which suggests passports should accommo-
Humanitarian News
W A B I P N E W S L E T T E R P A G E 14
date dierences between vaccines in their ecacy, register changes in vaccine ecacy against emerging variants, be inter-
naonally standardized and have veriable credenal. They should also be based on a plaorm of interoperable technolo-
gies, be secure for personal data, be portable and be aordable to individuals and governments
Taking into account all these consideraons, while the merits of vaccine passports may be undeniable, implementaon will
require ethical juscaons and praccal soluons that do not discriminate against the poor, the less technically literate,
and people from low and middle income countries. The policies to implement those passports will require a exible adapta-
on as we have learnt that pandemic policies that are sensible when launched may need to be rethought a month later.
Without migaon strategies for inequality of access and alternave soluons, the hardships experienced by marginalised
and vulnerable groups will be intensied through the perpetuaon of discriminaon.
The most formidable challenge of this me is to decrease the morally and praccally inadmissible levels of inequity all over
the world. That situaon represents not only a scandalous moral defeat but also a danger for democracy as we have known
it unl now. If not carefully, thoughully and ethically planned, the negave impacts of a cercaon system are likely to fall
disproporonately on those who are already socially marginalised and disadvantaged. Sociees globally must strive to en-
sure that passports are available to all in the most fair manner and with the highest respect for fundamental human rights.
*The views expressed in this arcle are those of the author (Silvia Quadrelli) 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.
1. Brown RCH et al. J. Med. Ethics. 2020;46:652-659.
2. Gosn LO et al. JAMA. Published online April 07, 2021. doi:10.1001/jama.2021.5283
3. Nueld Council on Bioethics. Rapid policy brieng: covid-19 anbody tesng and immunity cercaon.
2020. www.nueldbioethics.org/publicaons/covid-19-anbody-tesng-and-immunity-cercaon.
4. Osama T et al. BMJ. 2021 Apr 1;373:n861. doi: 10.1136/bmj.n861. PMID: 33795260.
5. Royal Society. Twelve criteria for the development and use of covid-19 vaccine passports. 2021. hps://royalsociety.org/-/media/
6. WHO. Interim guidance for developing a Smart Vaccinaon Cercate. hps://cdn.who.int/media/docs/default-source/documents/
interim-guidance-svc_20210319_nal.pdf?sfvrsn=b95db77d_11&download=true (accessed April 1, 2021)
7. WHO "Immunity passports" in the context of COVID-19, 2020. Available: hps://www.who.int/news-room/commentaries/detail/
immunity-passports-in-the-context-of-covid-19 [Accessed 27 Jan 2021].
Best Image Contest 2021 (2 of 3)
(A) Organized blood clot in the RLL
(B) Cryo-extracon of the clot
Dr. Syeda Samia Rasheed M.D
Best Image Contest
P A G E 15
This image is 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2020. Please stay
tuned to the next Image Contest opening later this year! Find the above image and more at the WABIP Acade-
my Image Library at hps://www.WABIPacademy.com/imagelibrary
P A G E 16
Maximising Yield for Molecular Analysis at EBUS TBNA
We are pleased to present to you our new, on-demand webinar
available to all for free. Follow the below buon to watch online.
In part 1 of the video presented by Prof. David Fielding, you will
Needle localisaon within nodes including the use of Doppler
The Importance of Good quality ROSE slides with ps on
Choice of collecon media
In the second part as presented by Prof. Sinchita Roy-Chowdhuri, you will nd:
Cytology preparaon
Pre analyc variables
Cellularity evaluaon
Specimen enrichment
Upcoming Events
8th Indonesian Pediatric Respiratory Meeng in conjuncon with The 3rd Asian Pediatric Intervenonal Pul-
monology Associaon Meeng
When: June 4-6, 2021
Where: Virtual / Indonesia
Program Director: Prof. Mohammad Ashkan Moslehi, Prof. Wahyuni Indawa
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Confer-
ence (didacc lectures)
Website: hps://iprm2021.id/
SCOPE 2021: Breaking Barriers in Lung Cancer (Philippines/Virtual)
When: June 23-25, 2021
Where: Virtual / Philippines
Program Director: Ronald A. Fajardo, MD
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.scope2021.net/
Introducon to Bronchoscopy and Pulmonary Procedures Course (USA)
When: June 27 and 30, 2021
Where: Beth Israel Deaconess Medical Center, Boston, MA, USA
Program Director: Mihir Parikh, MD
Program Type: Educaonal seminar (for trainees only), Hands-on workshop, Conference (didacc lectures)
When in Doubt-Cut it OutMay Not Be the Best Strategy Anymore
With the implementaon of lung cancer screening, albeit fragmented, the numbers of pulmonary nodules discovered have increased exponenally
in the United States and the rest of the world. However, our capability to predict malignant from benign nodules remains unreliable and limited.
Performing biopsies or surgically removing all high-risk nodulesis neither feasible nor sciencally sound, as shown by numerous clinical trials
including, the Naonal Lung cancer Screening Trial (NLST). NLST showed that more than 95% of surgeries in high-risk paentsrevealed non-
malignant nodules. Even with ever-evolving technologies such as navigaon and roboc bronchoscopies, sampling of nodules remains parcularly
quesonable when its negave.
Genec classiers are being developed and implemented to enhance pre and post-test probability of malignancy in pulmonary nodules to help
navigate invasive workup, parcularly, surgical procedures.
A study (1) of a genomic classier (Percepta) based on the eld of injuryassessed cancer-associated gene expression in cytologically normal-
appearing bronchial epithelial cells in the mainstem bronchus in paents undergoing bronchoscopies and is able to disnguish malignant pulmo-
nary nodules from benign lesions. The study looked at two dierent cohorts. Two independent prospecve cohorts revealed that the gene-
expression classier had high sensivity across dierent lesion sizes, locaons, stages, and cell types of lung cancer. The combinaon of the classi-
er plus bronchoscopy had a sensivity of 96% and 98% in the both (AEGIS-1 and AEGIS-2) validaon cohorts. Consequently, Percepta successfully
down-classied nodules with an intermediate pretest probability of malignancy (10%-60%) to a low-risk probability of malignancy (< 10%) with a
91% negave predicve value.
Another recent study published in CHEST 2021 (2) set out to evaluate the impact of Percepta on clinical decision-making in a real-worldseng.
This study is a mulcenter paent registry to observe a physician management of paents with pulmonary nodules who have had a nondiagnosc
bronchoscopy. Within that registry, the authors studied physician behavior and outcomes of decisions in paents with Percepta results. This sub-
set, the decision impact study,included documented physician risk assessment and decision-making results (planned and actual), in concert with
Percepta results to evaluate the impact on decision making of the test result.
In paents who were slated for invasive procedures (biopsy/resecon), the Percepta genomic classier downgraded one-third of (approximately
34%) of paents to lower risk of malignancy, precluding invasive procedures in approximately 79% of these downgraded paents for up to one
year. This study also showed that performing a genec classier tests did not delay in diagnosis of lung cancer.
Given this rapidly evolving data and the breadth of evidence, showing gene-expression classier improved the diagnosc performance of bronchos-
copy to detect lung cancer. Notably, in intermediate-risk paents with a nondiagnosc bronchoscopic examinaon, a negave classier score sup-
ports for a more conservave diagnosc approach.
I hope that our ability to predict the malignant potenal of a nodule improves substanally. Ulmately, we want to minimize unnecessary proce-
dures/resecon for non-malignant lesions and capture malignant lesions in me. Hence, when in doubt, consider genec classiers might be a
beer approach than cut it out.
Ali I. Musani MD
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 17
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
1. Silvestri GA et al; AEGIS Study Team. N Engl J Med. 2015 Jul 16;373
(3):243-51. doi: 10.1056/NEJMoa1504601. Epub 2015 May 17.
2. Lee HJ et al. Chest. 2021 Jan;159(1): 401-12. doi: 10.1016/
j.chest.2020.07.067. Epub 2020 Aug 3.
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
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