Volume 10
Issue 01
January 2022
Inside This Issue
Editorial, 2-3
Technology Corner, 4-6
Tips from the Experts, 7-9
Humanitarian News, 10-16
Best Image Contest, 17
WABIP News, 18
Research, 19-20
Links, 21
Ali Musani MD, FCCP
University of Colorado School of Medicine
Artificial Intelligence and Interventional Pulmonology
Are we “stepping in GOD’s shoes”?
WABIP Newsletter
J A N U A R Y 2 0 2 2 V O L U M E 1 0 , I S S U E 1
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
Arcial Intelligence (AI) is not a novel concept. The
word Arcial Intelligence was coined by John
McCarthy in 1956, and the rst general-purpose
mobile robot was developed in 1969. The rapid
growth in technology soon created Super Blue,the
supercomputer,which defeated the world chess
AI is a type of computer science used to create intel-
ligent machines that recognize human speech and
objects and learn, plan and solve problems like hu-
AI can be understood in many ways depending on
ones perspecve, as described below by some
world experts and leaders in the eld.
AI is just math - mulple computaons that are
the basis of AI are also where the technology faces
limitaons. Jana Eggers, the CEO of Nara Logics
AI is just soware. “Theres no bright line sepa-
rang AI soware from any other kind of computer
soware, Michael Liman, a computer science pro-
fessor at Brown University.
The potenal of AI lies in its ability to learn, and
its learning from humans. Mikhail Naumov, co-
founder, president, and CSO of Digital Genius.
Simply put, humans should be focused on teach-
ing machines, so that machines can focus on exe-
cung against jobs that are too big for humans to
process.” J.J. Kardwell, CEO/co-founder of Ever
In the eyes of some world experts of technology,
such as Elon Musk, CEO of Tesla, AI is a double-
edged sword. The potenal of AI is fundamentally changing
just about any aspect of our lives is so profound and self-
perpetuang that the threat of AI geng out of human
control makes him say that AI is a fundamental risk to the
existence of human civilizaon.
AI in medicine has been growing by leaps and bounds in all
facets, including diagnoscs, therapeucs, research, device
development, and drug development. Watson, the infa-
mous supercomputer, can diagnose thousands of diseases
with extreme expediency and accuracy. Numerous medical
organizaons now use it. Googles AI Rena Doctorcan
examine rena scans and diagnose diabec renopathy.
AI has also played a crucial role in the growth of Interven-
onal Pulmonology (IP) over the years. The below examples
will highlight some revoluonary AI-based developments in
LungVision system (Body Vision Medical LTD, Israel) is a
novel technology that integrates pre-procedural CT imaging
into augmented uoroscopic images, presenng real-me
visualizaon of the airways and locaon of the pulmonary
lesion during transbronchial navigaon and biopsy. It ena-
bles lesion tracking during breathing movement and im-
proves lesion localizaon and diagnosc yield. LungVision
may provide equivalent diagnosc outcomes to tradional
ENB plaorms at a fracon of the cost.
Opcal-based navigaon systems (such as SIRIO,
MASMEC S.p.A., Modugno, BA, Italy) perform Lung Thermal
Ablaon (LTA). Procedural planning, monitoring, and lesion
targeng are generally performed with the help of CT.
More recently, the implementaon of C-arm cone-beam CT
(CBCT) technology has introduced a new image guidance
strategy. Navigaon systems emerge as a valid tool to re-
duce procedural mes and administraon of radiaon dos-
es, allowing electromagnec, opcal, or hybrid tracking of
the devices used during intervenons and their real-me
visualizaon in a model obtained from a previously ac-
quired CT scan. In a recent study published in (1) opcal-
based navigaon system, SIRIO was shown to be an e-
cient tool to perform CT-guided LTA, displaying a signicant
reducon (p < 0.001) in the number of required CT scans,
procedure me, and paentsradiaon exposure.
A computer-aided diagnosis (CAD) system is a machine
learning texture model for classifying lung cancer subtypes
using preliminary bronchoscopic ndings is a CAD system.
This CAD system can disnguish cancer types to achieve an
P A G E 3
beer than the expert group.
In conclusion, AI has been advancing exponenally in every
walk of life, from essenal day-to-day funcons of turning on
a cell phone to ying ghter jets thousands of miles away
without a pilot. From human surveillance, nancial modeling,
fake news, invasive social media, educaon to religious
preaching. AI in medicine has enormous potenal to diagnose,
track, treat, and cure diseases. Like any other technology in
the past, it depends on how we use it.
1. Laimer G et al. Biology. 2021 Jul; 10(7): 644
2. Feng PH et al. Med Phys. 2018 Dec; 45(12):5509-5514
3. Way TW et al. Med Phys. 2009 Jul; 36(7): 30863098
4. Cui S al. Scienc Reports. 2020 10:13657
5. Zhi X et al. Front Oncol. 2021 May 31;11: 673775
objecve diagnosis. A study (2) collected broncho-
scopic images of 12 adenocarcinomas and ten
squamous cell carcinoma paents. The images
were transformed from a red-blue-green (RGB) to a
hue-saturaon-value (HSV) color space to obtain
more meaningful color textures. A predicon mod-
el of malignant types was established by combining
signicant textural features (P < 0.05) in a machine
learning classier. The performance of the CAD
system achieved an accuracy of 86% (19/22), sensi-
vity 90% (9/10), specicity 83% (10/12), posive
predicve value 82% (9/11), and negave predic-
ve value 91% (10/11) in disnguishing lung cancer
Another CAD system of a pulmonary nodule on
CT scans led to improved classicaon perfor-
mance with nodule surface features. A fully auto-
mated system was designed to segment the nodule
from its surrounding structured background in a
local volume of interest (VOI) and extract image
features for classicaon. A study (3) demonstrat-
ed that the CAD-based segmentaon and feature
extracon techniques are promising for classifying
lung nodules on CT images.
AI is showing rapid advantages and excing
achievements in diagnosc imaging and evaluaon.
Many novel deep neural network-based systems
have demonstrated the potenal for use in the
proposed technique for helping radiologists im-
prove nodule detecon accuracy with eciency
and cost-eecveness. In a study (4), 39,014 chest
low dose CT screening (LDCT) cases were retro-
specvely collected. The diagnosc performance of
the deep learning (DL) algorithm was evaluated in
the mul-center validaon set and the external
test set (LUNA). In total, 11,840,536 and 134,985
LDCT images obtained from 39,014 imaging studies
were assigned to the training set and validaon
set, respecvely. The DL model showed a high de-
gree of agreement with the reference standard.
In a study (5) of Automac Image Selecon
Model Based on Machine Learning for Endobron-
chial Ultrasound Strain Elastography Videos, the AI-
based technology showed 78.02% to 83.52% accu-
racy in diagnosing malignant from benign medias-
nal and hilar lymph nodes based on the relave
sness of the ssue. This accuracy was much
higher than the trainee group and equal to or
P A G E 4
Technology Corner
Augmented Imaging for Peripheral Bronchoscopy
Tradional guided bronchoscopy modalies include standard uoroscopy, radial ultrasound, and electromagnec guidance.
Despite evolving technology and tools, biopsy yields have remained around 70% in most studies. Roboc bronchoscopy
plaorms have emerged as opons for peripheral bronchoscopy with the promise of beer yields due to their ability to
beer reach peripheral regions of the lung, along with the ability to maintain vision during sampling, all while having beer
p stability especially in the case of eccentric lesions sampling. Despite this promise, the rst published studies showed
only modest improvement in yield (1,2). There are mulple reasons cited for subopmal yield; these include poor perfor-
mance of biopsy tools, local atelectasis that develops during the procedure, and CT-body divergence. Using cone beam CT
(CBCT), invesgators found that there can be signicant divergence in nodule locaon between the pre-procedure CT imag-
ing and lung during procedure (3). This divergence is largest in the lower lobes, and can be greater than 15mm in distance,
easily enough to rend a biopsy aempt spuriously away from the intended target, potenally resulng in a falsely negave
result. Accepng tool performance as a constant, it appears that accurate targeng of the nodule is therefore a major de-
terminant of yield. Up unl recently, the only surrogates of accurate targeng were uoroscopy and radial ultrasound
(rEBUS). Standard uoroscopy can only be employed when the nodule is visible, and rEBUS is mainly helpful when the le-
sion is concentrically posioned around the airway. Further, neither rEBUS or uoroscopy can provide accurate assess-
ments of distance and angular relaonships of the tool with the lesion. The emergence of CBCT has overcome these imped-
iments with detailed imaging and 3D reconstrucon, oering real insight into tool-nodule relaonship. Unfortunately, CBCT
is not readily available at all instuons and is expensive. As a result, other imaging modalies have been developed to
achieve the same goals. These modalies use enhanced uoroscopy images, and thus are less costly and use a much small-
er space footprint within the bronchoscopy suite, and therefore allow for broader adaptaon by proceduralists.
Augmented imaging refers to any real me imaging (ie uoroscopy) being augmented by other imaging sources (ie CT, ul-
trasound, etc). Mulple imaging modalies can then be fused (“image fusion”) simultaneously. Though imaging sources can
be real-me or historic, the augmentaon is real me. Currently there are several technologies on the market that achieve
augmented imaging, however only one, LungVision
(Body Vision Medical INC, NY) uses intraoperave tomography to aug-
ment real-me uoroscopy. The resultant augmented uoroscopic imaging contains an overlay of both the airway pathway
Joseph Cicenia, MD
Cleveland Clinic
P A G E 5
to the lesion, and the lesion itself (see Fig 1).
Clinical Applicaon:
How we do it
Aer the paent is anesthezed, a series of uoroscopy images are performed to achieve CT-body registraon. Then, a
uoroscopy spin (typically -50° to +50°) is performed with the nodule at isocenter. Aer images are reconstructed tomo-
graphically, nodule locaon is updated and the overlay appears for navigaon to begin. Once navigaon to the nodule is
completed, another uoroscopy spin is performed which gives 3D representaon of the nodule with the catheter and/or
biopsy tool, and nodule locaon correcons are performed if needed (see gs 2,3). Catheter and/or biopsy tool locaon
correcons can be made at this me, if necessary, and another spin can be performed to re-image tool-nodule arculaon.
Once the tool locaon and projected trajectory is deemed to be adequate, biopsies are done, again using augmented imag-
ing. Though uoroscopy use is increased during these procedures, cases have shown average doses around 250 mGy, about
one tenth that of a cardiac catheterizaon.
The applicaon of real-me imaging and localizaon during navigaonal bronchoscopy has promise, and has been suggest-
ed by results from mulple studies. For example, studies that have used advanced navigaonal technologies in conjuncon
with real-me CBCT imaging have suggested the addive nature of these technologies compared to their respecve individ-
ual yields (4). Indeed, published studies using LungVision have shown high localizaon rates (90-95% using rEBUS and
CBCT), albeit with earlier versions of the technology, with yield ranging between 77 and 84% (5,6). This compares well to
published rates of roboc bronchoscopy localizaon (85-90% range) and yield (1,2). It will be interesng to see if merging of
augmenng imaging (either CBCT or LungVision) with roboc bronchoscopy will result in higher yield procedures; studies
are commencing to evaluate this further.
It is apparent that augmented imaging can play an important role in peripheral bronchoscopy. Though this can be achieved
with CBCT, these systems are expensive, have large space footprints, and may be dicult to have access to. Using alterna-
ve technologies, such as LungVision, can provide similar imaging with standard uoroscopy equipment, and can be easily
incorporated into the bronchoscopy suite. Further research into the plaorm itself, as well as combining this plaorm with
roboc technologies is underway.
1. Kalchiem-Dekel et al. Chest. 2021 Aug 9;S0012-3692(21)03625-4
2. Chaddha et al. BMC Pulm Med 19, 243 (2019)
3. Pritche et al. J Bronchology Interv Pulmonol. 2021 Jan 1;28(1):10-20
4. Verhoeven et al. J Bronchology Interv Pulmonol. 2021 Jan 1;28(1):60-69
5. Pritche,et al. J Bronchology Interv Pulmonol. 2021 Apr 1;28(2):107-115
6. Cicenia et al. J Bronchology Interv Pulmonol. 2021 Apr 1;28(2):116-123
P A G E 6
Figure 1: Augmented imaging overlay with pathway and nodule.
Figure 2: Tomographic reconstrucon of nodule with
catheter leading into it.
Figure 3: 3D reconstrucon of the nodule-catheter
Tips from the Experts
P A G E 7 V O L U M E 1 0 , I S S U E 1
Diagnosc procedures for sampling peripheral pulmonary lesions (PPL) have developed remarkably over the last two decades as more lung
nodules are being idened due to liberalized lung cancer screening guidelines, increasing prevalence of chronic lung disease, and improve-
ments in advanced chest imaging. Two such plaorms include electromagnec navigaon bronchoscopy (ENB) and roboc assisted bron-
choscopy (RAB), which overall have improved diagnosc yield for PPL sampling [1-6].
When using ENB or RAB, proprietary planning soware uses computed tomography (CT) of the chest with thin-slice protocol (1 mm cuts)
obtained during full inspiraon to build a virtual bronchoscopic image of the tracheobronchial tree. A computer-generated pathway from
the target lesion to a more centrally located airway is constructed, and the bronchoscopist can manually adjust and extend the mapped
pathway as needed. This pathway serves as a guide to the target lesion during bronchoscopy. During the procedure, the main plaorm gen-
erates an electromagnec eld around the paents chest. This enables synchronizaon of a probe or sensor with the CT scan, and the bron-
choscopist can track the synchronized probe or sensor while navigang through the airways.
During the pre-procedural planning phase, the bronchoscopist may adjust or extend the computer-generated pathway by selecng and add-
ing points along visible airways on the CT chest from the target lesion to the central airway. This is oen known as the bronchus sign”,
which is dened as the presence of an airway leading directly to a pulmonary lesion. The presence of a bronchus signhas been associated
with an improvement in diagnosc yield. In a meta-analysis of 2,199 lesions, the diagnosc yield was reported as 74.1% when a bronchus
signwas present vs 49.6% in its absence [7]. Seijo and colleagues also reported an increased diagnosc yield of PPL sampling with ENB with
the presence of a bronchus sign(79% vs 31%) [8]. Likewise, the diagnosc yield of PPL sampling by RAB was reportedly increased with the
presence of a bronchus signin a mul-center study by Chaddha and colleagues (78.3% vs 54.1%) and in the BENEFIT trial (75.0% vs 72.7%)
[2,4]. The large mul-center NAVIGATE trial evaluang the ENB system by Medtronic also demonstrated that the presence of a bronchus
signwas associated with higher diagnosc yield (78.3% vs 67.1%) [9].
However, prior studies have reported that up to 40% of paents lack a bronchus signwhen undergoing navigaonal bronchoscopy espe-
cially in paents with emphysema, in which the resoluon of the CT chest is subopmal for idenfying peripheral airway walls [8,10-12].
Therefore, alternave strategies in these sub-group of paents are necessary to provide navigaon precision. Recognizing that vessels, lym-
phacs and airways are oen adjacent in the bronchovascular bundle, in paents where a vessel is seen leading to the target nodule there
should also be a conguous airway which may not be seen on the CT due to the lack of contrast between the peripheral bronchi and sur-
rounding lung parenchyma (Figure 1). The evidence supporng vessels as a surrogate for a bronchus signon CT is well corroborated by
developmental biology as blood vessels develop at the same me as airways; and specically, the pulmonary arteries run alongside the air-
ways and the pulmonary veins show a similar branching paern to the arteries [13,14]. Therefore, a vessel sign”, dened as a vessel leading
directly to a target lesion, can be used as a surrogate for mapping during pre-procedural planning when a bronchus signis absent (Figure
Using the Vessel Signfor Pre-procedural Planning in Navigaonal and
Roboc Bronchoscopy
Sepmiu Murgu, MD
The University of Chicago
Elliot Ho, DO
Loma Linda University
Tips from the Experts
P A G E 8 V O L U M E 1 0 , I S S U E 1
During the pre-procedural planning phase, the CT chest is rst imported into the planning plaorm. Once segmentaon is complete, the
bronchoscopist idenes and marks the target lesion. The proprietary soware then constructs a computer-generated pathway towards the
target lesion, which may be incomplete and require manual adjustment. By appreciang the airways and vessels leading to the target lesion
on pre-procedural CT, the bronchoscopist can manually adjust and extend the computer-generated pathway by tracing over and adding
points along such airways and vessels from the target lesion towards the central airway. In our experience with ENB and RAB, we have had
success using the vessel signas a backup pathway when the registraon CT scan lacked a clear bronchus sign(Figure 2).
It should be noted, however, that the advancement of navigaonal technology for PPL sampling is not a replacement for experience and
thoughul review of imaging and airway anatomy. Successful planning of a pathway for PPL sampling using navigaon plaorms requires
appropriate understanding of the tracheobronchial anatomy.
Airway inspecon using a convenonal white light bronchoscope is typically performed prior to convenonal ENB and RAB to rule out central
endobronchial lesions and aspirate secreons if present. Navigang to the target lesion via guided bronchoscopy using the virtual pathway
created on the pre-procedural planning soware is then used (Figure 2). Before sampling the target lesion, successful localizaon to the tar-
get lesion is demonstrated based on feedback from the navigaon system and typically conrmed with a second method of visualizaon (e.g.
r-EBUS, uoroscopy, cone beam CT, augmented uoroscopy) (Figure 2). Once localizaon is conrmed, endoscopic tools are passed via the
working channel of the bronchoscope to sample the target lesion. The presence of rapid onsite cytology evaluaon (ROSE) allows for real-
me conrmaon of whether lesion material is obtained. While ROSE provides value regarding ssue adequacy for molecular proling, it is
unclear whether the use of ROSE aects the diagnosc accuracy for sampling parenchymal lesions [9].
Quality Control
Any soware that uses a CT performed at total lung capacity will lead to CT-body divergence, in which the true locaon of a PPL is not always
consistent with the navigated virtual target, under the condions of general anesthesia. This is due to the dierences in lung volume at the
me of the planning CT scan and when the actual procedure is performed. This is especially true when the target lesion is in the lower lobes,
in which atelectasis is more prevalent during general anesthesia and there is more diaphragmac excursion. Real-me imaging has been the
emphasis of more recent technology to improve PPL localizaon.
Radial EBUS has been shown to conrm proper placement of the sampling tools and verify its proximity to the target lesion, increasing diag-
nosc yield [1,10,15]. Prior to the introducon of RAB, the paern of r-EBUS image usually aected diagnosc yield, in which a higher yield
was noted when concentric r-EBUS views are obtained (84%) as compared with eccentric r-EBUS views (48%) [16]. The alignment of the bron-
choscope working channel in relaon to the target lesion can be adjusted based on the radial EBUS view. Eberhardt and colleagues reported
that the combined use of r-EBUS along with ENB improved diagnosc yield of up to 88% as compared with either technology alone [17]. With
RAB, some studies show that the yield is not aected by the r-EBUS paern [2,4].
Digital tomosynthesis via augmented uoroscopy (AF) with convenonal C-arm and cone-beam computed tomography (CBCT) aempt to
correct for CT-body divergence and provide real me feedback of the bronchoscope or tool locaon. This is in eort to allow for ne adjust-
ments of ENB or RAB to beer align the working channel with the target lesion and assist with redirecng sampling tools as needed, increas-
ing localizaon success and potenally diagnosc yield [3,18-20]. To date, there is no evidence, however, that these technologies signicantly
improve diagnosc yield when compared with RAB technology alone.
Advancements in navigaonal bronchoscopy and advanced imaging techniques have empowered bronchoscopists to access the periphery of
the lung with more condence and increasing accuracy. As newer advancements in navigaonal bronchoscopy and soware connues to
develop, the ability of the bronchoscopist to recognize and plan pathways to the target lesions is even more important.
The vessel signcan be used as a potenal surrogate for the bronchus signwhen mapping a pathway for navigaonal bronchoscopy and
an airway leading to the lesion cannot be visualized. Potenally, the use of the vessel signduring pre-procedural planning may be able to
improve the rate of navigaon success for ENB and RAB procedures that lack a bronchus sign”. Studies are needed to conrm the validity of
using the vessel signfor pre-procedural planning during navigaonal bronchoscopy and clarify its eect on outcomes including rate of local-
izaon success, diagnosc yield, and complicaon rates.
Tips from the Experts
P A G E 9 V O L U M E 1 0 , I S S U E 1
1. Folch EE et al. Chest. 2020 Oct; 158(4):1753-1769.
2. Chen AC et al. Chest. 2021 Feb; 159(2):845-852.
3. Pritche MA et al. J Bronchology Interv Pulmonol. 2018 Oct; 25(4):274-282.
4. Chaddha U et al. BMC Pulm Med. 2019 Dec; 11;19(1):243.
5. Chen AC et al. Ann Thorac Surg. 2018 Jul; 106(1):293-297.
6. Chen AC et al. Respiraon. 2020 Jan; 99(1):56-61.
7. Ali MS et al. Ann Am Thorac Soc. 2018 Aug; 15(8):978-987.
8. Seijo LM et al. Chest. 2010 Dec; 138(6):1316-21.
9. Folch EE et al. J Thorac Oncol. 2019 Mar; 14(3):445-458.
10. Ali MS et al. Respirology. 2017 Apr; 22(3):443-453.
11. Brownback KR et al. J Bronchology Interv Pulmonol. 2012 Apr; 19(2):91-7.
12. Hsia DW et al. J Bronchology Interv Pulmonol. 2012 Jan; 19(1):5-11.
13. Hall SM et al. Am J Respir Cell Mol Biol. 2000 Aug; 23(2):194-203.
14. Loosli CG et al. Am Rev Respir Dis. 1959 Jul; 80(1, Part 2):5-23.
15. Kurimoto N et al. Chest. 2004 Sep; 126(3):959-65.
16. Chen A et al. Ann Am Thorac Soc. 2014 May; 11(4):578-82.
17. Eberhardt R et al. Am J Respir Crit Care Med. 2007 Jul; 176(1):36-41.
18. Aboudara M et al. Respirology. 2020 Feb; 25(2):206-213.
19. Cicenia J et al. J Bronchology Interv Pulmonol. 2021 Apr; 28(2):116-123.
20. Casal RF et al. J Thorac Dis. 2018 Dec; 10(12):6950-6959.
Figure 1. The Vessel Sign”. CT image in the axial
plane showing a subsolid peripheral nodule
(yellow arrow) without a bronchus sign (A). How-
ever, a pulmonary artery branch was idened
(blue arrow) leading to the nodule (B).
Figure 2. Using the Vessel Signfor Lung Nodule Sampling
with Roboc Bronchoscopy. The nodule (yellow arrow) is
seen in the lateral segment of the right middle lobe (A). A
vessel (blue arrow) is seen leading to the nodule and was
used for manual planning (B). The roboc bronchoscope is
advanced to the target lesion and parked proximal to the
lesion while vision is sll maintained by air insuaon (C).
Fluoroscopy shows the sheath, scope and radial EBUS probe
(D). Radial EBUS image shows a small eccentric nodule
(highlighted by the doed line) conrming successful navi-
gaon (E).
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
Ethical Issues about Waiving Intellectual Property Protecons for COVID-19
In 1796 Edward Jenner developed the rst vaccine by taking material from cowpox lesions on a cow maid and injecng it
into an eight-year-old boy. Several weeks later, he injected the boy with live smallpox, with no ensuing infecon. The World
Health Organisaon (WHO) has only ever declared two diseases exnct: the cale disease rinderpest, and one human dis-
ease, smallpox. Both were the result of massive vaccinaon drives and global campaigning.
However, the road to eradicaon was not an easy one. The technical and sanitary challenges (parcularly in tropical coun-
tries) seemed impossible to be overcome. In the 1950s, Leslie Collier developed a freeze-dried vaccine. In the following dec-
ade, Benjamin Rubin of Wyeth Laboratories designed the bifurcated needle, which made easier a reliable vaccinaon. These
technical developments but mainly the decision to waive patents and royales on the needle and vaccine, enabled the WHO
to launch its 1966-1977 campaign to eradicate smallpox globally and aer 14 years of careful searching and contact tracing
and millions of vaccines one of the biggest killers in history was eradicated.
In the last century, few diseases have reached a global devastang eect on mortality in the form of outbreaks of major epi-
demics. Probably because of that, even when vaccinaon (together with hygiene and sanitaon measures) have dramacally
improved life expectancy, the concept of vaccines as a public good was slowly fading.
But now that vaccine inequity leaves lower income countries many of them in Africa at the mercy of COVID-19, the ethi-
cal discussion about the moral duty of developed naons for waiving patents to vaccinate more quickly the global south has
become not only necessary but also urgent.
WHO has set a global target of 70 per cent of the populaon of all countries to be vaccinated by mid-2022, but to reach this
goal a more equitable access to vaccines will be needed. And this is not a necessity only for the underserved communies
with insucient access to vaccinaon, this is an urgent need for the whole world. As Dr Tedros Adhanom Ghebreyesus, the
Director-General of the World Health Organizaon (WHO) said vaccine equity was not rocket science, nor charity. It is smart
public health and in everyones best interest.
The ethical principles guiding the distribuon of vaccines should be considered, especially for those at high risk. It is well
known that from late December, 2020, countries started vaccinang their populaons, however, those millions of available
doses were concentrated in high-income countries, which have purchased 54% of secured doses but which account for only
19% of the global populaon.
The right balance between private prots and public health is not a new issue but a long-running debate. Many experts and
humanitarian NGOs contend that World Trade Organizaon (WTO) rules on intellectual property (IP) limit poor countries
access to crical medicines. On the other hand, defenders of conceiving essenal medicines as any other commodies, point
that the IP rules are needed to incenvize drug makers.
Unfortunately, ethical principles in health policy have oen been neglected when they have concerned vulnerable groups,
with the distribuon of life-saving drugs judged too expensive and unsustainable and the recipients considered unworthy.
Lack of foresight, incenves, and polical will has caused a serious violaon of the principle of jusce and the consideraon
of access to health care as a universal human right.
But beyond the general principle that ethical allocaon of every kind of health care resources is crucial for the principle of
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W A B I P N E W S L E T T E R P A G E 11
jusce, the massive and rapid spread of COVID-19 epidemic and the associated high rates of mortality have
turned necessary an urgent debate about an essenal moral queson: is it ethically acceptable to uphold vaccine patents
during a global shortage?
The naturalizaon that low-income countries should and can spend substanally less on saving the lives of their vulnerable
groups, sadly indicates that the value of one's life is linked to their country's income. And during a dramac emergency as a
lethal but potenally preventable disease, it has shone a harsh spotlight on the fact that the global community accepts that
the lives of those in low-income countries are worth less than the lives of those in high-income countries. The valuaon of
life solely based on where an individual lives generates unethical guidelines about health policies that negate an individual's
human right to health.
The WTOs Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) commits members to guaranteeing
twenty-year patents and safeguards for copyrights, trade secrets, and industrial designs, prevenng companies other than
the inventors from manufacturing those medical products. Based on warranng the access to crical medicines globally, in
late 2020, a group of low-income countries led by India and South Africa proposed that the WTO temporarily waive IP pro-
tecons for vaccines unl most of the worlds populaon gets immunizaon. This would allow other companies, including
those in developing countries, to make generic brands of exisng vaccines. The U.S. and E.U., as well as countries including
the UK, Japan, and Australia among others, opposed the proposal while over 100 other countries have supported the waiver.
In May 2021, the Joe Biden administraon reversed course and announced its support for a vaccine IP waiver. Not much
later, a coalion of developing countries pressing for the waiver, submied a new proposal quite similar to the rst that
specied that the waiver would apply to pandemic-related health products and technologies, and advising the waiver
should last for at least three years.
As a result of those events, a heated debate has been seled worldwide. But two dierent aspects need to be dierenated
about this issue. On the one hand, controversy may exist about the ecacy of the waiver in its goal of raising access to Covid
-19 vaccines in poor countries, based on the dicules of companies in developing countries to learn from the original pro-
ducers how to produce eecvely in the short run and the lack of vaccine producon facilies and technology. It is argued
that the absence of patents will do lile to remedy the structural deciencies that impede a quickly expanding producon
capacity in developing countries on the scale and speed needed to a large scale producon that solve the access problem.
But, although the argument that the patent waiver will, by itself, do lile to address the short-run access problems is proba-
bly right, a very dierent issue is the ethical legimacy of upholding the patents and deliberately denying access to some
populaons in the pursuit of prots or in order to give priority to certain groups.
Analyzing the subject strictly from a moral point of view one could apply the argument that vaccine patent waivers could
allow other countries to produce generic copies and increase the global supply of vaccines and that the increase of vaccines
availability could save lives and decrease the prevalence of future COVID variants, which is threatening to prolong the pan-
From a Kanan perspecve, the answer seems crystal clear. Maintaining patents violates the principle of benecence, doing
good for others, by deliberately refusing to help countries in dire need. It also violates the principle of non-malecence,
avoiding harm to others, as patents can discourage innovators from other countries from developing a novel vaccine for fear
of copyright suits.
All the social actors are also moral agents including policy makers, CEOs of mulnaonal companies and scholars or inven-
tors. Being as they are human beings, they must face every day the same queson we all human face: is my behavior morally
correct, am I honouring my own humanity? We know that all persons, regardless of rank or social class, have an equal intrin-
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W A B I P N E W S L E T T E R P A G E 12
sic worth or dignity. Human dignity is an innate worth or status that we did not earn and cannot forfeit. Rather, we must
strive to make our individual choices worthy of this moral standing, which elevates us above animals and mere things. Kant
expresses the principle of humanity (PH) as follows: Act in such a way that you treat humanity, whether in your own person
or in the person of any other, never merely as a means, but always at the same me as an end”. It is a principle, Kant holds,
that would describe the conduct of fully raonal beings toward themselves and each other, so it is a principle that should
describe the conduct of human beings toward themselves and each other.
That respect for human dignity requires that everyone fulls his or her duty. In The teleological argument, Kant disnguishes
among: a) the case in which a person clearly acts contrary to duty; b) the case in which a person's acons coincide with duty,
but are not movated by duty; and c) the case in which a person's acons coincide with duty because he or she is movated
by duty. And Kant (and much of the post-Kanan philosophy) explicitly expresses that our acons only have moral worth and
deserve esteem when they are movated by duty. Those consideraons led to the construcon of the Categorical Impera-
ve. Kant characterized the CI as an objecve, raonally necessary and uncondional principle that we must always follow
despite any natural desires or inclinaons we may have to the contrary. Thus, the supreme formal principle of Kants ethics
is: Act only on that maxim through which you can at the same me will that it should become a universal law.”
And so the queson is: can any human being wish that the rule that nancial prot must be always preserved (even at the
cost of hundreds of thousands of preventable deaths) become a universal law? And if not: is any reward treasured enough to
choose acons against our raonal duty and consequently with no moral worth and that does not deserve any esteem and
deny our own humanity?
Crics of the proposal argue that a waiver would discourage future innovaon. The technology ulized by the Pzer-
BioNTech and Moderna vaccines were only possible through years of research and development from the public and private
sector. If companies have no prot incenve to create these new health care products, investments in the industry drop and
this could lead to a decline in new technologies. It has also been menoned that it would create a potenal disadvantage for
US companies if allowing China and other rival countries to obtain essenal IP. The primary basis for this arguments is that
the prots IP generates are essenal to spur innovaon and discovery which in turn, advance societys interests. The ques-
on is, even if it were true: how much nancial incenves are needed, how much money does it take? In 2021, Pzer/
BioNTech will make 1530 billion US dollars from COVID-19 vaccine sales, Moderna 1820 billion US dollars, and Johnson &
Johnson 10 billion US dollars. Could these companies earn less and the incenve to innovate remain intact?
Helping others may always have a cost. Even Kant menons that helping others is an imperfect duty”, and in his concepon,
an imperfect duty allows exibility—benecence is an imperfect duty because we are not obliged to be completely bene-
cent at all mes, but may choose the mes and places in which we are. Big companies may argue (and do argue) that they
are not charitable organizaons, that looking for the highest possible prots is a legimate aim and that they can choose
how and when help others. However, as the notorious contemporaneous philosopher Peter Singer has shown in his famous
book The life you can save”, that exibilityis far from being unlimited.
Singer exemplies that situaon in the simple but categorical philosophical experiment of the drowning child. On your way
to work, you pass a small pond. You see a child splashing about in the pond and by geng closer, you see that he is ailing
about, unable to stay upright or walk out of the pond. There is no one else around. If you don't wade in and pull him out, he
seems likely to drown. Wading in is easy and safe, but you will ruin the new shoes you bought only a few days ago, get your
suit wet and muddy and you will be late for work. What should you do? Predictably, most of people respond that you should
save the child. The premise behind that well known story is: if it is within our power to prevent something bad from happen-
ing, without thereby sacricing anything of comparable moral importance, we ought, morally, to do it. In a similar way, we
may ask ourselves (beyond the praccalies of the real impact of the waiver of patents) if thousands and thousands of
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W A B I P N E W S L E T T E R P A G E 13
deaths and the consequences of collapsed economies are not worthy of sacricing some minor nancial prots.
The essenal feature of capitalism is the move to make a prot and one of its founding pillars is self-interest, through which
people act in pursuit of their own good, without regard for sociopolical pressure. Nobody expects that neither entrepre-
neurial businesses nor big rms resign their purpose of making prot or work for losing money. But the queson is: are the
big pharma companies that develop and manufacture vaccines at the risk of losing money?
Between 2000 and 2018, 35 big drug companies received a combined revenue of $11.5 trillion, with a gross prot of $8.6
trillion. The median net income margin reported by 35 pharma companies between 2000 and 2018 was almost twice as high
as it was for the 357 non-pharma companies included in the comparison. Funding for pharmaceucal research and develop-
ment (R&D) is the result of a complex mix of private and public sources. Governments mainly support basic and early-stage
research. Such funding is made through direct budget allocaons, research grants, publicly-owned research instuons and
funding of higher educaon instuons. The pharmaceucal industry translates and applies knowledge generated by basic
research to develop products, and invests in large clinical trials required to gain market approval. The industry also receives
direct R&D subsidies or tax credits in many countries. But despite the pharmaceucal rms are substanally supported by
government subsidies, yet the price for most medical products is mulple mes the producon cost. In products whose
availability put lives of people at stake, the invisible handof the market if far from being balanced, as the access to drugs
and medical technologies is not a maer of choice but of essenal need. Addionally, the huge eort made by the research-
ers is not a solitary endeavor. The thousands of volunteers that made the tesng needed for the approval of the new vac-
cines possible, the previous basic research on what the new developments are based, the pilots of planes and drivers of
trucks who transported the vaccines, the thousands of health care workers involved in the organizaon and implementaon
of the vaccinaon campaigns that did not take any addional prot, all of them were indispensable components of the net-
work required for the vaccines reach every single target subject.
The margins of prots of the big pharma companies has become a heated debate in many countries in the last years. Many
have quesoned that subsidies given by the governments come from the taxes paid by cizens including vulnerable groups,
and the deliberate decision to sell drugs at extremely high prices let those same vulnerable groups that support them by
taxes deprived of their right to health because they cannot aord them. In fact, although this year the rapid and eecve
development of COVID-19 vaccines improved substanally their popularity, for decades, few industries in the US have been
as unpopular as Big Pharma.
Many scholars and social and polical acvists trusted that new winds were arriving in the world economy as a reacon to
the many failures that a previously successful system as the capitalism is showing currently all over the world. Many of the
worlds eco-systems are on the edge of collapse, inequality increases persistently, and systemic racial and ethnic exclusion
disgrace every society on the planet. Even business leaders are voicing these opinions with crics to convenonal capitalism
and accepng that it is in urgent need of redempon. Ajit Ranade, president of Aditya Birla Group even said capitalism is
losing support because of its failure to address widening inequalies. In that sense, one of the challenges seemed to be a
renewal of the purpose of the rms—away from only maximizing shareholder value towards including solving public prob-
lems protably and avoiding creang new problems’. It would allow the private sector to become an acve partner in cre-
ang a just and sustainable society. Many enthusiasc analysts saw an example of that in the inial commitment of Pzer to
provide ered pricing for middle-income countries while providing the vaccine for free in Africa. However, many of Pzer's
contracts requesng guaranteeing the company indemnity and forcing the governments to compensate for any adverse
eects of the vaccine, faded any hope to ensure ethical cosng.
Many conservave economists all over the world sll support the Milton Friedmans theory that the social responsibility of
business is to increase its prots and that a corporaon is a morally neutral legal construct with maximising returns for
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shareholders as its single purpose. But even with that self-centered understanding of business, nobody should deny the un-
matched value of a human life. The pandemic has transformed the discussions about the impact of inequalies, unfairness
and unethicalness from abstract speculaons to concrete daily pictures of human deaths. Figures, pictures and personal his-
tories hit us right in the face every day from the news and the social media. Addionally, the polical manipulaon of the
pandemic has created many obstacles for a raonal management of the epidemic. The vaccine development process has
been linked to elecon cycles in many countries, with polical leaders making not always accurate promises about the vac-
cine which reduced the trust that individuals have in the results of what appear to be rushed clinical trials. An-vaccine
groups have gained popularity increasing enormously their followership base since 2019. An irresponsible behavior of many
news media and the undeniable history of unethical exploitaon of vulnerable groups caused vaccine hesitancy in many pop-
ulaons in dierent countries, increasing the risk of death and suering from the disease.
The principle behind the campaign to temporarily waive IP protecon for COVID vaccines is that every country should have
the right to make its own vaccines during a pandemic. Waiver is surely not the only or even the best soluon to increase
access and the implementaon of the waiver engenders several intrinsic challenges. The tools and technologies required for
this purpose are currently owned by only a few pharmaceucal companies and probably not all countries would have on-site
pharmaceucal industries that can guarantee adequate protecve measures both for the technicians in the laboratories or
for the surrounding populaons. High safety levels for the associated biological risk are required and dicult to achieve. Na-
onal health surveillance procedures may not be as strict as desirable to monitor potenal risks and side eects. Producon
in condions of imperfect biological quality control could result in more adverse reacons. Obviously, loosening the grip of IP
protecons is not a miracle x, and there are many other barriers to a safer world. All of these are important arguments, and
need to be addressed. But they are not, in themselves, reasons for denying IP relief.
A study by the WHO Regional Oce for Europe and the European Centre for Disease Prevenon and Control (ECDC) es-
mates that 470 000 lives have been saved among those aged 60 years and over since the start of COVID-19 vaccinaon
rollout in 33 countries across the WHO European Region, not including lives saved by vaccinang people under 60 nor those
saved from the indirect eect of vaccinaon because of a reducon in transmission. Denying or delaying access to vaccina-
on costs lives, concrete singular lives with names and beloved ones. And no one more death is morally aordable having
the resources to prevent it.
Countries backing the IP waiver are not asking for charity, but for the right to develop and make their own vaccines, free
from the worry that they will be sued by patent holders.
The rapid development of several vaccines against COVID-19 is an unequalled scienc accomplishment, but the absence of
a system that secures equitable access to vaccines has uncovered deep inadequacies in the global governance systems for
health. We must crically examine our moral principles when it comes to vulnerable groups, pressing pharmaceucal com-
panies, normave agencies, and polical leaders to commit to an ethical behavior and pushing for iniaves that rst and
foremost promote ethical and equitable soluons.
Aording priority on the basis of economic or polical power is a clear deviaon from the public-health principles of maxim-
izing lives or life-years saved, and the commitment of assuring that lifesaving resources should not depend on naonality.
The United Naons (UN) Sustainable Development Goals (SDGs) instruct that universal preparedness for health requires a
radical systems approach: health must be seen in the broadest of contexts, with due aenon to social structures and infra-
structure, working and living condions and with strategies to counteract climate change, loss of biodiversity and human
destrucon of wild habitat.
A pandemic teaches that no one should be le behind and that no one is safe unl everyone is safe, and COVID-19 made
evident the consequences of not having health insurance or access to healthcare, not having water or a food supply during
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W A B I P N E W S L E T T E R P A G E 15
lockdown situaons, or not having civil rights. However, the COVID-19 pandemic has shown the weak adherence of wealthy
naons to the commitments of that UN Agenda 2030, mainly the leaving no one behind’. It has revealed democrac decits,
instuonal rigidity, weak accountability systems, and inadequate policy space that protects health-governance systems
from economic goals. We have seen how decient global accountability mechanisms are, and the consequences of leaving
health care at the mercy of its commercial determinants were clearly exhibited. The absence of legally binding mechanisms
that hold market actors accountable for failing to act for the public good and the consequences of this lack of proper regula-
ons were crudely exposed.
COVID epidemics has also shown that an ecient and independent supranaonal governance system is needed to take the
role of an eecve global coordinaon for medicines and vaccines be rapidly ready to be equitably delivered when an epi-
demic erupts.
The WHO is facing a crisis which is increasingly challenging the authority and presge of the United Naons' specialized
agencies in general and WHO in parcular. Global health,should really imply the consideraon of the health needs of the
people of the whole planet above the concerns of parcular naons. There are many concerns that the agencys legimacy
and authority in global health maers have been undermined, showing that WHO priories are disproporonately inu-
enced by a few powerful donors. But the present mes require that supranaonal organizaons must be strengthened, not
undermined. A not minor issue is that realigning WHOs nancial structure would likely safeguard both the agencys autono-
my and member statestrust, while alleviang concerns about undue inuence from powerful donors.
This crisis has taught that updated global governance mechanisms are needed that beer reect the contemporary geopo-
lical order and truly encourage internaonal collaboraon across sectors, through polical and legal soluons rooted in
commitments to jusce and shared global responsibility. The debate about the waiver of patents has brought wider debates
about pharmaceucal company power, predominance of geopolical strategy and lack of commitment to decrease the im-
pact of health inequalies. It is not simply the maer to become lost in the lights and shadows of a patent waiver. What
must remain clear is that the issues of jusce (equitable distribuon), benecence (helping other countries), and non-
malecence (avoiding harm to other countries) must be the priority of individuals and polical leaders.
This pandemic has been and it is sll being a dramac experience for any human being wherever and however they live. But
we cannot be fooled about it: we are not all in it together. COVID-19 is experienced unequally, with much more tragic conse-
quences for the most disadvantaged communies: it is not a socially neutral disease. We have seen as never before how the
impact of a disease is magnied by the pre-exisng social determinants of health, such as housing and work condions and
access to quality healthcare. We cannot aord adding to those long-term condions the deliberate restricons of the access
to the only current resource to decrease the disaster of COVID-19: the vaccinaon.
We are only risking our new shoes; we have only one morally acceptable choice: we must rescue the drowning child if we
want to rescue our own human dignity.
*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.
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W A B I P N E W S L E T T E R P A G E 16
1. Bozorgmehr K et al. Lancet. 2021 Apr 3;397(10281):1261-1262
2. Editorial: A patent waiver on COVID vaccines is right and fair. Nature. 2021 May; 593(7860):478
3. Ekström AM et al. Nat Med. 2021; 27, 739740
4. Iacobucci G et al. BMJ 2021;373:n1182
5. Jecker NS et al. J Med Ethics. 2021;47:595-598
6. Nioi M et al. J Clin Med. 2020 Apr 16;9(4):1138
7. Rouw A et al. J Global COVID-19 vaccine access: a snapshot of inequality. hps://www.k.org/policy-watch/global-covid-19-
vaccine-access-snapshot-of-inequality/ Date accessed: December 10, 2021
8. Nioi M et al. Front Med (Lausanne). 2021 Nov 4;8:756623
Best Image Contest 2022 (1 of 3)
60 years old gentleman presented with insidious onset of stridor and exeronal dyspnea aer endotracheal
intubaon for a Killip-4 anterior myocardial infarcon a year ago. CT scan conrmed a ght stenosis at the
subgloc region which was successfully treated with balloon dilataon and mitomycin C applicaon via rigid
bronchoscope. Paent subsequently underwent denive surgical correcon successfully.
Dr. Kho Sze Shyang & Dr. Jamalul Azizi bin Abdul Rahaman
Best Image Contest
P A G E 17
This image is the 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2021. Please
stay tuned to the next Image Contest opening later this year. Find the above image and more at the WABIP
Academy Image Library at hps://www.WABIPacademy.com/imagelibrary
P A G E 18
Annual Board of Regents Meeng
This meeng shall be held on Saturday, March 12, 2022, and the Regents who represent their member society
will parcipate and vote on items mandated in our bylaws. The meeng is an integral part of compleng our an-
nual registraon to retain our status as a non-prot organizaon in Tokyo Japan.
WCBIP 2022 Marseille France
Marseille 2022 World Congress is coming this October in hybrid
format, and we could not be more excited to kick start our
oerings to WABIP members. We invite you to start the sub-
mission process for:
Abstracts (Deadline May 2, 2022) Guidelines & submission
link at hps://www.wcbip.org/abstracts
Video Fesval (Deadline July 1, 2022) Guidelines & submis-
sion form at hps://www.wcbip.org/videofesval
WABIP Awards (Deadline July 1, 2022) Guidelines & submission forms at hps://www.wabip.com/
Registraon for on-site and online parcipaon will be open in February 2022.
Endoscopic Ultrasound Secon New members welcome
We are proud to announce that 190 members have joined this
new WABIP secon, and we are embarking on many related pro-
jects and acvies. We can sll accommodate a few new mem-
bers, and we welcome you to apply for Endoscopic Ultrasound
secon membership via hps://www.wabip.com/forms/
9th Asian Pacic Congress on Bronchology & Intervenonal Pulmonology
We would like to announce that the Asia-Pacic congress will now
take place in April 2023, moved from original October 2021 date. Dr.
Jamalul Azizi and his organizing commiee will will ensure an ex-
cing program with didacc lectures, case-based discussions, virtual
hands-on workshops, and more. Stay tuned to all related updates at
What Are the Necessary Technologies and Techniques for Transbronchial Ablaon of
Pulmonary Nodules?
Ablaon techniques, including radiofrequency ablaon, microwave ablaon (MWA), and cryoablaon, are promising treatments for malig-
nant pulmonary nodules. Compared to percutaneous approaches, transbronchial ablaon therapy for pulmonary nodules has a more favourable
safety prole by virtue of avoiding pleural puncture (1-3), although the cumulave clinical experience remains limited. Challenges with transbron-
chial approaches include increased diculty accessing peripheral nodules and managing the ablaon margin, whereby potenal injury to the pleu-
ra and other major structures must be avoided.
A recent retrospecve study from Chan and colleagues (4) is informave and thought-provoking on successful transbronchial treatment of
pulmonary nodules. They summarized results from transbronchial MWA of 30 pulmonary nodules with electromagnec navigaon bronchoscopy
(ENB) guidance in a single instuon. Their procedure in a hybrid operang room included the following technologies: 1) cone-beam computed
tomography (CBCT) at baseline, aer posioning the catheter pre-MWA, and post-MWA, 2) ENB to navigate the MWA catheter to the target
uoroscopy), and 3) the Transbronchial Access Tool (TBAT) for accessing targets without a bronchus sign. Twenty-two nodules (73%) were in the
peripheral-third lung eld. Pneumothorax requiring chest tube inseron and hemoptysis occurred in 2 and 1 cases, respecvely. Transbronchial
MWA achieved local control over the follow-up period of median 12 months.
For pulmonary nodule ablaon, precise tool placement is essenal. Navigaonand conrmaonare separate components of precise
placement. Commercially-available navigaon modalies include virtual bronchoscopic navigaon, ENB, and augmented uoroscopy. They help
guide inseron of the bronchoscope and tools into the appropriate bronchus faster. However, selecng the correct bronchus does not mean the
tool p is opmally posioned. This disncon is important when deriving guidance from preprocedural CT images, as CT-to-body divergence
needs consideraon (5). Venlaon and instrumentaon can distort the regional parenchyma, resulng in a discrepancy between the expected
target locaon (i.e., based on preprocedural CT) and the actual target locaon just prior to ablaon. Consequently, the posion of navigated
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief WABIP
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 19
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
Tsukasa Ishiwata, MD, PhD
University Health Network
Kazuhiro Yasufuku MD, PhD
University Health Network
Alexander Gregor, MD
University Health Network
tools relave to the nodule must be conrmed by other modalies. Those oen used clinically include radial probe endobronchial ultra-
sound (RP-EBUS) and CBCT.
In the context of ablaon, CBCT has an advantage over RP-EBUS in that it can conrm catheter posion relave to the target and to
surrounding ssues, perming more precise calculaon of both the potenal ecacy and safety of the ablaon zone.
A major challenge with transbronchial ablaon, regardless the navigaon and conrmaon technologies used, is that target access
has convenonally depended on the presence of a feeding bronchus. Chan and colleagues overcame this issue by using TBAT. The TBAT (6),
and other plaorms like it (7), create alternave transbronchial routes to the target by tunnelling through the lung parenchyma from a pre-
selected bronchial puncture point. These techniques will be vital for successful ablaon of nodules without a bronchus sign, avoiding the
need for excessively large ablaon elds to fully encompass distant peribronchial targets.
To successfully and safely perform transbronchial ablaon of pulmonary nodules, several advanced technologies and techniques
are required. More studies are needed to condently conclude on the performance and safety of transbronchial ablave therapies. Moreo-
ver, the learning curve and cost-eecveness of combining such technologies have not been fully evaluated. Chan and colleagues have, how-
ever, established an important benchmark to guide future work.
1. Koizumi T et al. Case Rep Oncol Med. 2013;2013:515160.
2. Xie F et al. Respiraon. 2017;94(3):293-8.
3. Pritche M et al. CHEST. 2020;158:A1452-3.
4. Chan JWY et al. Transl Lung Cancer Res. 2021;10(4):1608-22.
5. Pritche MA et al. J Thorac Dis. 2020;12(4):1595-611.
6. Anciano C et al. J Bronchology Interv Pulmonol. 2017;24(3):253-6.
7. Sa S et al. Lung Cancer. 2018;124:125-9.
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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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