Volume 13
Issue 02
May 2025
Inside This Issue
Editorial, 2-3
Technology Corner, 4-6
Tips from the Experts, 7-8
Humanitarian News, 9-14
Best Image Contest, 15
WABIP News, 16
Research, 17-18
Links, 19
9th Edition TNM Classification for Lung Cancer
WABIP Newsletter
M A Y 2 0 2 5 V O L U M E 1 3 , I S S U E 1
EXECUTIVE BOARD
Pyng Lee, MD, PhD
Singapore, Chair
Ali Musani, MD
USA, Vice-Chair
Stefano Gasparini, MD
Italy, Immediate Past-Chair
Hind Janah, MD
Morocco, Membership
Commiee Chair
Aleš Rozman, MD, PhD
Slovenia, Educaon Com-
miee Chair
Danai Khemasuwan, MD
USA, Finance Commiee
Chair
Naofumi Shinagawa, MD
Japan, Secretary General
Rajesh Thomas, MD, PhD
Melbourne , President
WCBIP 2026
STAFF
Michael Mendoza
General Manager
Judy McConnell
Administrator
Kazuhiro Yasufuku
Newsleer Editor-in-chief
P A G E 2
Introducon
Since 1996, the Internaonal Associaon for the
Study of Lung Cancer (IASLC) has developed infra-
structure to rene successive edions of TNM.
1
A
clear and consistent nomenclature about the ana-
tomical extent for lung cancer is important to enable
reliable communicaon and assessment of clinical
trial applicability to an individual paent.
The 9
th
edion TNM classicaon of lung cancer
came into eect in January 2025, replacing the pre-
vious edion from 2017.
2
As advances in diagnosis,
imaging and treatment for lung cancer evolve, there
is a need to update lung cancer staging. The cohort
of paents from the 8
th
edion was from 1999 to
2010, whilst the 9
th
edion ulised a cohort of pa-
ents from 2011 to 2019.
1
This new edion contains
mulple changes that lung cancer clinicians should
be aware of.
Key updates in the 9
th
edion (gure 1, changes
highlighted in red)
2
T staging
There are no changes in the 9
th
edion to the T stag-
ing category.
N staging
The 9
th
edion has subdivided N2 into N2a (nodal
metastasis to a single N2 staon) and N2b (mulple
N2 staons). The new staging does not suggest any
changes to the IASLC nodal map (gure 2).
The IASLC staging project proposed this change due
to recognion that mulple N2 staons confer
worse survival compared to a single N2 staon. This
dierence between N2a and N2b was consistent
across histologic type, resecon status, geographic
region and T category.
3
M staging-
The 9
th
edion staging has subdivided the M1c category
into M1c1 (mulple extrathoracic metastases in a single
organ system) and M1c2 (mulple extrathoracic metastases
in a mulple organ system).This change was proposed due
to the worse survival of the two groups.
4
Stage Groups
By changing the N2 and M1c subgroups, the new staging
had to incorporate them into new staging groups. In addi-
on, T1N1 was down-staged from eighth edion stage IIB
to 9th edion stage IIA. These changes are illustrated in
gure 3.
The assignment of T1N2a to Stage IIB is the most radical
change in the 9th edion, as in the past N2 disease has
been classied into Stage III. N2b disease remains in stage
III, in line with the worse prognosis of mul-staon N2 dis-
ease.
All these changes were adequately validated in subset anal-
yses involving both clinical and pathologic stage cohorts.
5
Clinical implicaons
The 9
th
edion TNM staging incorporates dierences in the
number of involved mediasnal lymph nodes and number
of metastac sites, which convey stascally signicant
dierences in overall survival.
N staging will require greater precision from radiologists,
praconers of invasive staging procedures, surgeons and
pathologists to provide sucient informaon between sin-
gle staon N2 and mul staon N2 metastasis. For exam-
ple it will mandate that mulple N2 nodes are sampled dur-
ing invasive staging procedures.
The M staging reects that there is a signicant survival
dierence between metastasis in a single organ system and
mulple organ systems. As advances in metastac lung
Brandon Wong, MD
Clinical Fellow, Division of Thoracic Surgery,
Toronto General Hospital, University Health Network
W A B I P N E W S L E T T E R P A G E 3
cancer treatments develop, there is an emerging
concept of oligometastac disease as a unique
enty. This group of paents could benet from
specic and possibly curave metastasis directed
ablave opons, such as with surgery and radio-
therapy.
Limitaons of TNM staging and future direcons
The current staging system does have several
limitaons in how it can incorporate factors that
aect cancer survival and treatment responsive-
ness. For example there are proven nonanatomic
tumour related factors that are important for
systemic therapies (e.g. presence/absence of driv-
er mutaons, PD-L1 expression).
2
There are also
addional histologic descriptors that aect cancer
prognosis but do not aect T staging (e.g. presci-
ence of spread through airway spaces [STAS], lym-
phac invasion, lymphac carcinomatosis).
2
The next edion of lung cancer staging should
incorporate how newer treatment modalies
have eected paent prognosis. As individual
and mulmodality treatments advance, it creates
an increased focus on tumour extent in the more
advanced stages. Going forward will be im-
portant for databases to include more descripve
data about nodal and metastac disease, which
will guide the next edion of TNM staging.
References
1. Asamura H et al. J Thorac Oncol. 2023; 18:564-
575
2. Deerbeck F et al. CHEST 2024; 166(4)882-895
3. Huang J et al. J Thorac Oncol. 2023; 19(5)766-785
4. Fong K et al. J Thorac Oncol. 2024; 19(5)786-802
5. Ramon R et al. J Thorac Oncol. 2024; 19(7)1007-
1027
Figure 1: 9
th
Edion TNM staging
Figure 2: AISLC Lung Cancer Lymph Node Map
Figure 3: Comparison of 8th and 9th
edion TNM categories
W A B I P N E W S L E T T E R P A G E 4
Technology Corner
Spray Cryotherapy in Post-Lung Transplant Bronchial Stenosis
Introducon
Bronchial stenosis is a common and serious complicaon following lung transplantaon, occurring in up to 24% of paents and sig-
nicantly impacng morbidity, quality of life, and gra funcon. It typically arises within the rst-year post-transplant and can occur
at an anastomoc site or extend distally to the segmental airways. The underlying mechanism of post-transplant bronchial stenosis
is poorly understood. However, it may be related to maladapve wound healing in the seng of airway inammaon and ischemic
injury of the donor airway with the loss of bronchial arterial blood supply. Management of bronchial stenosis frequently requires a
mulmodal approach, including dilaon, ablaon, and stent placement for refractory cases. Addional adjuvant therapies to im-
prove wound healing including steroid injecon and mitomycin C applicaon have also been used, with varying results. While these
intervenons are frequently successful in improving airway patency, a durable response is oen dicult to achieve, and there is a
signicant burden of frequent bronchoscopies and repeated intervenons.
Spray cryotherapy (SCT), which has demonstrated safety and ecacy in esophageal disease, is gaining tracon in pulmonary medi-
cine as a novel non-contact therapy that may address the underlying broinammatory pathology of airway stenosis. This arcle
highlights recent instuonal experience with SCT in lung transplant recipients and explores its role in reducing procedural burden
and stent dependence.
Background
SCT delivers liquid nitrogen (LN) through a catheter posioned via exible or rigid bronchoscopy. LN causes rapid cooling in the con-
text of spray cryotherapy through its extremely low boiling point of -196°C. When LN is sprayed onto the target ssue, it rapidly
evaporates and expands (1 mL liquid to 700 mL gas) upon contact with the warmer ssue surface. This phase change from liquid to
gas absorbs a signicant amount of heat from the ssue, leading to a rapid drop in temperature. The expansion of LN to gas during
spraying enhances the cooling eect by increasing the surface area of contact between the cryogen and the ssue. This ensures a
more uniform and eecve cooling. This process forms ice crystals within the cells and extracellular space, causing cellular destruc-
on through ice crystal formaon while preserving the basement membrane of carlage, collagen, and elasn. Following the rapid
freeze is a gradual rewarming. This thaw cycle enhances ssue destrucon through cellular damage, immune response acvaon,
and oxidave stress. The controlled injury promotes regenerave rather than broc healing, dierenang SCT from thermal abla-
ve methods, which oen cause excessive scarring.
Chris Yurosko, DO
Intervenonal Pulmonology Fellow
Respiratory Instute - Department of
Pulmonary, Allergy and Crical Care
Medicine & Transplant
Cleveland Clinic
Sonali Sethi, MD, FCCP, D-AABIP
Intervenonal Pulmonology
Director, Lung Cancer Diagnosis and
Staging Program
Program Director for Intervenonal
Pulmonary Fellowship & Fellows Procedural
Training
Respiratory Instute - Department of
Pulmonary, Allergy and Crical Care Medicine
& Transplant Cleveland Clinic
W A B I P N E W S L E T T E R P A G E 5
Proper venng of the gaseous nitrogen generated during the procedure is crical to prevent complicaons such as barotrauma and
pneumothorax. Studies have shown that adequate egress of nitrogen gas is necessary for safe use. This venng allows for the safe
and eecve applicaon of LN spray cryotherapy without undue side eects.
Clinical Applicaon
In a mulcenter retrospecve study by Fernando et al. (2011), 35 paents with benign airway strictures underwent 63 SCT sessions.
Of those available for follow-up, 85% reported symptomac improvement, and endoscopic evaluaon conrmed anatomical im-
provement in most cases. Only one pneumothorax was reported among all procedures.
Building on this experience, Janke et al. (2016) evaluated SCT in malignant and benign airway disease paents. In the subgroup of 10
paents with benign stenosis—9 of whom had post-lung transplant strictures—80% achieved Grade I (mild) stenosis post-treatment.
Though not stascally signicant due to the small sample size, the study highlighted the potenal of SCT as a benecial intervenon
in the transplant populaon.
A retrospecve cohort study at a high-volume transplant center, Cleveland Clinic evaluated SCT in 13 lung transplant recipients with
bronchial stenosis. All paents had prior airway intervenons, and most had stents at the me of SCT iniaon. A total of 47 SCT pro-
cedures were performed using the truFreeze system (Steris), with a mean follow-up of 10.8 months.
Key procedural safeguards were employed, including low-ow delivery of LN, conrmaon of gas egress, and pauses between treat-
ments to allow gas clearance. There were 3-5 cycles per procedure with each spray lasng 10 seconds and being performed under
general anesthesia.
• Bronchoscopy burden: The mean rate of bronchoscopy prior to SCT was 0.64/month. Aer compleon of SCT, this was reduced
to 0.28/month in a subset of paents with at least 6 months of follow-up—a stascally signicant reducon (p=0.036).
• Stent dependence: Of 8 paents with stents at the start of SCT, 7 underwent successful stent removal. At follow-up, 6 remained
stent-free. The stent use rate dropped from 62% to 15% (p=0.016).
Safety prole: SCT was well tolerated. The most common intra-procedural complicaon was transient hypotension related to general
anesthesia inducon (36%), which resolved without sequelae prior to SCT being iniated. One pneumothorax (2% of procedures)
occurred, requiring chest tube placement.
Conclusions:
This early clinical experience supports the feasibility and safety of SCT in a lung transplant populaon with complex airway disease
and signicant prior intervenon history. The observed reducon in bronchoscopy frequency and stent dependence suggests that
SCT may play a disease-modifying role rather than being merely palliave.
While inial data are promising, important limitaons exist, including the small sample size, retrospecve data, single-center design,
and relavely short follow-up. All paents in this study were treated at the bronchus intermedius. While the results may be general-
izable, safety and ecacy in other anatomic locaons—especially more distal airways—need further invesgaon.
W A B I P N E W S L E T T E R P A G E 6
While SCT is not currently a rst-line therapy for bronchial stenosis, it is emerging as a useful adjunct or alternave in refractory cas-
es. Its ssue-sparing mechanism and favorable safety prole make it a compelling opon for select paents. The early evidence sug-
gests that SCT may contribute to:
• Prolonged airway patency
• Reduced frequency of intervenons
• Increased success of stent-free management
Future prospecve, mulcenter studies are needed to conrm these ndings and to dene standardized treatment protocols, op-
mal paent selecon criteria, and long-term outcomes.
References
1. Fernando HC et al. Ann Thorac Surg. 2011;91(5):1570–1575.
2. Janke KM et al. J Thorac Dis. 2016;8(9):2560–2567.
3. Kheir F et al. Chest. 2016;150(4):1141–1146.
4. Moore RF et al. J Thorac Dis. 2017;9(2):E150–E155.
5. Finley DJ et al. Ann Thorac Surg. 2012;94(1):199–204.
Figure 1.
A: Le mainstem anastomosis with anastomoc, perianastomoc and lobar stenosis prior to rst SCT treat-
ment (green circle indicang le upper lobe division, blue circle indicang le lower lobe),
B: Two months following iniaon of SCT with two treatments consisng of 5 sprays. (green circle indicang
le upper lobe division, blue circle indicang le lower lobe),
C: Most recent bronchoscopy nearly three years aer iniang SCT therapy. (green circle indicang le upper
lobe division, blue circle indicang le lower lobe),
Tips from the Experts
P A G E 7
V O L U M E 1 3 , I S S U E 1
Bronchoscopic lung volume reducon (BLVR) is a minimally invasive procedure using small endobronchial valves (EBV) to treat emphysema
marked by hyperinaon. While BLVR improves pulmonary funcon and dyspnea, one of the complicaons is pneumothorax. The incidence
of pneumothorax following BLVR is between 14-26% .
1,2
Development of a pneumothorax following BLVR can result in morbidity and ex-
tended length of stay (LOS) for paents. Furthermore, post-BLVR pneumothoraces can pose signicant challenges for treang physicians.
Algorithms have been developed for the management of pneumothoraces following BLVR.
3
While pathways provide steps to help manage
pneumothoraces, they do not delineate at what point in the post-BLVR period these intervenons should be performed. Many physicians
have diculty knowing when to implement steps along the pathway and when to determine if an EBV should be removed.
Responses to intervenons performed within the rst 72-hours following a BLVR-related pneumothorax are crical. The presence or ab-
sence of improvement can determine whether EBVs should remain in the paent or be removed. Decisions in this period can provide realis-
c expectaons for recovery along with a nite me regarding the short-term outcomes of the procedure.
Placement of a chest tube for a post-BLVR pneumothorax typically provides clinical stability. Immediately following chest tube placement,
the catheter should be placed to wall sucon of -20 mmHg. The presence of a PAL aer chest tube placement is common. If a paent devel-
ops venlatory failure, severe hypoxia, or signicant subcutaneous emphysema while on wall sucon one or all EBVs should be removed. In
these situaons, the paent is unable to tolerate the complicang pneumothorax even with chest tube placement.
In paents with a stable pneumothorax on wall sucon, the management goal in the rst 72-hour post-BLVR is to successfully transion the
paent to water seal. Water seal is a method of chest tube drainage using water as a barrier to prevent air from entering the chest during
inhalaon but allows air to escape during exhalaon. When water seal is tolerated, the amount of air escaping into the pleural space from
the defect causing the pneumothorax is like the air removed by the chest tube. If stability on water seal can be achieved, there should be
condence that the PAL will resolve, with the average me to chest tube removal being 16.9 days.
4
A paent is considered stable on water
seal when there is no increasing oxygen requirement, worsening shortness of breath or chest pain, and absence of new subcutaneous em-
physema. If any of these occur, the paent is inappropriate for water seal and should be aached back to wall sucon.
On post-operave day 1 aer chest tube placement, paents should undergo a water seal trial. If the paent tolerates the water seal trial,
then they should remain o sucon. If unable to tolerate water seal, air evacuaon from the pleural space is likely inadequate due to the
chest tube diameter. In this seng, the paent should have the chest tube upsized to at least an 18 French catheter or have an addional
chest tube placed. The increased diameter or number of the chest tubes may help adequately evacuate pleural air.
Once the diameter or number of chest tubes has been opmized, a daily water seal trial should be performed on post-operave days 2 and
3. If stable on water seal, discussions should be had with the paent about remaining in the hospital unl the PAL resolves or discharge
home with a mini-atrium. In the laer case, weekly outpaent visits could occur to determine when the chest tube can be removed. If water
seal trials fail on post-operave day 2 and day 3, then removal of one EBV should be performed to facilitate healing of the PAL. While physi-
cians and paents can connue to aempt daily o sucon, the likelihood of transioning to water seal is unlikely or will take a prolonged
period. This may result in increased risk of pleural infecon and potenally signicant decondioning. Instead, at least one valve should be
removed with plans for reinseron approximately 8-12 weeks following resoluon of the PAL.
Pneumothoraces following BLVR can be challenging for both paents and physicians. Uncertainty about chest tube management and the
ming of intervenons can be frustrang. The rst 72 hours aer a post-BLVR pneumothorax can be telling of the short-term outcome of
the complicaon and the likelihood for PAL resoluon. Understanding the response to chest tube management in the rst 72 hours aer a
BLVR pneumothorax can help facilitate care and recovery.
Chest Tube Management in the First 72-Hours Following Post-Bronchoscopic Lung
Volume Reducon (BLVR) Pneumothoraces
Amit “Bobby” Mahajan MD, FCCP, DAABIP
Secon Chief, Inova Intervenonal Pulmonology
Department of Thoracic Surgery
Falls Church, VA USA
Tips from the Experts
P A G E 8
V O L U M E 1 3 , I S S U E 1
1. Criner GJ et al. Am J Respir Crit Care Med. 2018 Nov 1;198(9):1151-1164.
2. Criner GJ et al. Am J RespirCrit Care Med. 2019 Dec 1;200(11):1354-1362.
3. van Dijk M et al. Respiraon. 2021;100(10):969-978.
4. Mahajan AK et al. J of Bronchology Interv Pulmonol. 2023. Sept 13.
Figure 1: Chest Tube Management First 72-Hours Following Post-BLVR Pneumothorax
Humanitarian News
W A B I P N E W S L E T T E R P A G E 9
Challenges of Internaonal Humanitarian Acon in a Geopolical
Order Threatened by Democrac Erosion
Internaonal humanitarian eorts achieve their greatest ecacy in environments where democrac processes operate rm-
ly and eecvely. The essenal values of humanitarian work—neutrality, imparality, independence, and humanity—
necessitate an environment characterised by civil liberes, the rule of law, and the separaon of powers. Only consolidated
democracies guarantee the civic space essenal for humanitarian organisaons to funcon without arbitrary interference,
approach vulnerable communies devoid of polical constraints, and preserve their operaonal autonomy against govern-
mental pressure. Democrac erosion signies not merely a polical crisis but also a fundamental threat to the internaonal
humanitarian system, whose protecve and assisve mechanisms fundamentally rely on democrac norms that priorise
human needs above polical power, geopolical interests, or electoral consideraons.
The realm of internaonal humanitarian acvity has experienced signicant adjustments in recent decades, increasingly in-
uenced by structural alteraons in the global geopolical framework and, notably, by the ongoing decline of democrac
systems. The systems that have historically facilitated humanitarian aid are presently encountering unparalleled challenges
amid a climate of increasing fragility in liberal democracies and a profound reconguraon of polical power dynamics due
to digital technology.
Steven Levitsky and Daniel Zibla 's How Democracies Die (2018) and Giuliano da Empoli's Engineers of Chaos (2019) provide
complementary analycal frameworks for understanding the nature and scope of this crisis. While these works do not explic-
itly address humanitarian issues, their examinaons of democrac decline, social polarisaon, digital manipulaon, and po-
lical instrumentalisaon are crucial for contextualising the current challenges confronng humanitarian relief. Examining
these works is essenal for understanding how the evoluon of democrac spaces and the rise of new authoritarianism are
altering the context for internaonal humanitarian eorts.
The book "How Democracies Die?" by Steven Levitsky and Daniel Zibla (Harvard University) is a reference work for under-
standing the processes of democrac deterioraon in the contemporary polical context. Published in 2018, this work has
incited much scholarly and public discourse regarding the risks confronng contemporary democrac systems. The book's
fundamental premise holds that contemporary democracies do not usually collapse through military coups or violent events,
but through a gradual, legal, and impercepble process of erosion. Levitsky and Zibla argue that the greatest danger to 21st
-century democracies comes from democracally elected leaders who, once in power, systemacally undermine democrac
instuons from within ( Levitsky & Zibla , 2018). This phenomena, occasionally termed "stealth authoritarianism," is de-
ned by behaviours that, when considered individually, may appear lawful or inconsequenal, but which together constute
a paern of democrac deterioraon. Therefore, it can be said that "by the me people realize, it's already too late" ( Levit-
sky & Zibla , 2018). The incremental nature of this process makes it dicult to idenfy threats early and complicates the
acvaon of democrac defense mechanisms.
The authors idenfy four indicators of authoritarian behavior that indicate when a leader or polical movement may pose a
threat to democracy:
1. Rejecon of democrac rules : Quesoning elecon results, suggesng constuonal manipulaon, or refusing to
accept electoral defeats.
2. Denial of legimacy of opponents : Viewing polical rivals as existenal threats to the naon, treang them as
"enemies of the people" rather than legimate competors.
3. Tolerance or encouragement of violence : Explicit support or lack of condemnaon of polical violence carried out by
followers or other related groups.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
4. Predisposion to restrict civil liberes : Intenon to limit the freedom of the press, expression or assembly of oppo-
nents, including aacks on the credibility of the media.
Levitsky and Zibla rigorously examine their idea through both modern and historical situaons that they believe illustrate
these processes. During Hugo Chávez's tenure, Venezuela underwent a process in which his unmistakable charisma and sub-
stanal popular backing facilitated the consolidaon of power within the execuve branch, progressively undermining the
separaon of powers and instung measures to suppress dissenng voices. This process is mirrored in Turkey, where Recep
Tayyip Erdoğan has solidied his power by systemacally undermining instuons that ought to funcon independently of
the execuve branch. Hungary exemplies a quintessenal instance of modern democrac decline. Under Viktor Orbán, a
constuonally elected leader, the naon has undergone a systemac erosion of democrac instuons that has profoundly
altered the Hungarian polical scene. Donald Trump's presidency in the United States has ignited vigorous scholarly dis-
course over how his unique speech as well as certain acts may pose possible dangers to the norms and instuons that sup-
port the American democrac system. Recently In Argenna, a naon with robust democrac principles that acvely up-
holds human rights post the 1976 military dictatorship, the far-right administraon of democracally elected President Javier
Milei has altered the polical landscape by employing pseudo-legal taccs to undermine parliamentary acons and dismiss
judicial resoluons.
History also oers valuable lessons about these processes. The Weimar Republic in Germany illustrates how the rise of poli-
cal extremism, combined with structural weaknesses in instuonal design, created the condions for the eventual rise of
Nazism. Similarly, Fascist Italy under Benito Mussolini demonstrates how a leader with authoritarian tendencies can use le-
gimate electoral processes to build popularity before beginning a systemac process of erosion of democrac instuons.
According to the authors, the era preceding the American Civil War, despite its temporal remoteness, serves as a historical
illustraon of how severe social and polical polarisaon, along with the disintegraon of mutual tolerance between con-
icng polical groups, can precipitate a society's descent into democrac failure.
The primary point of Levitsky and Zibla's work is that, irrespecve of the perfecon of formal instuonal designs, they are
ineecve without the presence of democrac behaviours that uphold and invigorate these standards. In this context, draw-
ing from the North American experience, the authors delineate two categories of unwrien norms that are essenal for the
democrac system: a) mutual tolerance and b) instuonal self-restraint. Mutual tolerance entails acknowledging the adver-
sary as merely an opponent rather than an enemy; it involves recognising that, despite diering perspecves and visions, as
long as they adhere to constuonal principles, they possess an equal right to exist, vie for power, and govern. Self-restraint
denotes "paent self-control, temperance, and tolerance" or "the act of abstaining from exercising a legal right." It denotes
"eschewing acons that, although compliant with the leer of the law, contravene its spirit." The authors cauon that de-
mocracies are not eternal, and their endurance relies on the public resolve to safeguard them from challenges that may,
ironically, emerge from the democrac process itself. In a historical context marked by the ascendance of authoritarian
tendencies globally, Levitsky and Zibla's appeal for the preservaon of democrac values and instuons is especially per-
nent and essenal.
On the other hand, the work "The Engineers of Chaos" by the Italian-Swiss essayist and novelist Giuliano Da Empoli (2019)
emerges as an incisive analysis of the role that digital strategists and informaon technologies have played in the recent rise
of populism and the extreme right worldwide. Da Empoli (Instut d'études poliques de Paris) conceptualises the emerging
dynamics of polical manipulaon in the digital era and their ramicaons for modern democrac instuons. The principal
argument of "The Engineers of Chaos" asserts that digital plaorms have evolved from imparal tools that democrase in-
formaon access to environments that generate "organised chaos," mostly beneng authoritarian and populist facons..
Da Empoli remarked in an interview with La Repubblica (2019) that "what we are witnessing is not merely a technological
evoluon, but a polical revoluon that is redening the parameters of the democrac framework." Digital plaorms have
enabled chaos to be ulised as a weapon of power.
The exploitaon of chaos is seen in the strategic applicaon of algorithms, big data analycs, and psychographic segmenta-
on methods to inuence public opinion. In contrast to convenonal polical propaganda, these novel approaches provide
unparalleled accuracy in pinpoinng suscepble audiences and tailoring communicaons intended to manipulate their anxi-
ees, resentments, and biases. Da Empoli presents the noon of "polical technology" to highlight the sophiscaon in-
volved in ulising digital tools to shape public opinion. The study reveals that social media algorithms intenonally promote
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W A B I P N E W S L E T T E R P A G E 11
divisive content due to its ability to elicit increased engagement, resulng in "algorithmic polarisaon." This creates a detri-
mental cycle in which extreme content gains heightened visibility, thereby exacerbang user radicalisaon and the fragmen-
taon of public discourse.
Da Empoli focuses on the gures operang behind the scenes, those digital strategists who, working away from public scru-
ny, have managed to decisively inuence the outcome of important polical contests. He highlights gures such as Steve
Bannon, Donald Trump's former strategist, and Dominic Cummings, architect of the Brexit campaign. These strategists are
disnguished by their capacity to gather and analyse extensive data sets, enabling them to deliver highly targeted messages
to various voter demographics, exploing their weaknesses and intensifying exisng societal divisions. The rise of these spe-
cialists in digital manipulaon signies the professionalisaon of online polical inuence, wherein the capacity to manipu-
late data and algorithms is an essenal tool for aaining power. Da Empoli designates what he refers to as "indignaon mar-
keng" as a crucial approach of contemporary populism. This strategy involves methodically incing and leveraging animosi-
ty towards convenonal instuons, mainstream media, and polical elites. In this scenario, post-truth polics arises, as
objecve facts diminish in signicance against contrived narraves that resonate with the emoons and biases of parcular
audiences. A troubling outcome of the current polical landscape is that, in the post-truth era, the architects of chaos disre-
gard objecve truth; rather, they manipulate contradicons and ambiguity in informaon to foster distrust in convenonal
media and democrac instuons. Truth transforms into a baleground, where facts hold lile signicance in comparison to
the emoonal resonance of statements. The manipulaon of emoons via social media engenders parallel realies, wherein
disparate groups of the populaon possess fundamentally divergent perspecves on the same occurrence. This phenomena
erodes the foundaon of democracy, which relies on a requisite level of unanimity regarding truth and facts.
Digital plaorms have created "informaon bubbles" wherein consumers predominantly engage with content that corrobo-
rates their preexisng prejudices, obstrucng discourse and consensus over polics. In a 2019 interview with El País, Da Em-
poli asserts: "When individuals exist within insular informaon bubbles, they forfeit the capacity to empathise with those who
hold divergent perspecves." This engenders a fractured society in which polical discourse devolves into a cultural conict.
This remark underscores how digital polarisaon exacerbates wider social and polical conicts, leading to a crisis of con-
dence in democrac instuons.
The book serves as a crucial warning about how digital plaorms, far from fullling their promise of democrasing access to
informaon and fostering more inclusive public debate, have been co-opted by actors seeking to exploit chaos for polical
ends. By exposing the strategies and taccs employed by the "engineers of chaos," Da Empoli contributes to a greater
awareness of the vulnerabilies of our democrac systems in the digital environment.
In short, both books concur that contemporary democracies are suscepble to the deterioraon of essenal values and that
numerous democracies are progressively declining in non-violent however radical manners, although they highlight disnct
reasons for this decline. Levitsky and Zibla contend that democracies rely on informal norms like mutual tolerance and reci-
procity among polical actors; when these norms deteriorate, authoritarian leaders can subvert democrac instuons in-
ternally. Conversely, Da Empoli emphasises that digital technologies have fostered an environment where tradional demo-
crac norms, such as trust in the media and electoral systems, are being undermined by disinformaon and mass manipula-
on. Instead of facing direct assault, these norms are subverted by the widespread disseminaon of erroneous and divisive
narraves.
Democrac erosion as a threat to humanitarian space
What is the eect of these noons on the humanitarian sector in a seng characterised by an increase in both the frequen-
cy and severity of armed conicts, parcularly aecng civilian populaons? Levitsky and Zibla assert that the "democrac
demise by myriad diminuons" has obvious ramicaons for internaonal humanitarian eorts.
In environments where essenal democrac principles—like mutual tolerance and instuonal restraint—are being under-
mined, humanitarian organisaons encounter heightened limitaons on their operaonal capabilies. Leaders exhibing
authoritarian inclinaons oen manipulate humanitarian aid, restricng access to at-risk groups based on polical criteria or
employing resource allocaon as a tool for social control and power consolidaon.
This situaon is especially pronounced in what Levitsky and Ziblarefer to as "illiberal democracies," when electoral proce-
dures remain intact while oversight mechanisms and fundamental rights are deliberately undermined. According these au-
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W A B I P N E W S L E T T E R P A G E 12
thors, countries such as Hungary, governed by Viktor Orbán, and Turkey, led by Recep Tayyip Erdoğan, illustrate how demo-
cracally elected administraons can gradually constrict civic space, imposing arbitrary regulaons on non-governmental
organisaons, criminalising aid to migrants or refugees, and fostering naonalist discourses that undermine the legimacy of
internaonal humanitarian intervenon.
The erosion of the separaon of powers and judicial independence progressively eliminates the instuonal mechanisms
that have tradionally protected humanitarian space. When courts, parliaments, and independent regulatory bodies lose
autonomy from the execuve branch, humanitarian organizaons are exposed to arbitrary decisions without eecve legal
recourse. The persecuon of humanitarian workers, the freezing of NGO assets , or the imposion of insurmountable admin-
istrave restricons thus become tools of polical control disguised as legality.
Da Empoli's analysis in The Engineers of Chaos complements this perspecve by examining how digital technologies are be-
ing used to erode the democrac consensus that has historically underpinned internaonal humanitarian acon. Da Empoli
argues that "what we are witnessing is not a simple technological evoluon, but a polical revoluon that is redening the
rules of the democrac game" (2019). This transformaon profoundly impacts the ability of humanitarian organizaons to
operate eecvely in increasingly polarised contexts.
The fragmentaon of informaon produced by algorithms that priorize divisive and extreme content has progressively un-
dermined the social consensus on the importance of humanitarian aid. As Da Empoli points out, these polical microtar-
geng techniques , exemplied by the Cambridge Analyca case, facilitate the "exploitaon of vulnerabilies and exacerba-
on of exisng social divisions", transforming humanitarian concerns into ideological conicts. The resultant polarisaon
undermines the social and polical backing essenal for maintaining eecve humanitarian iniaves, while validang nav-
ist and isolaonist discourses that depict foreign aid as opposed to naonal interests.
This "outrage markeng" has proved notably eecve in undermining essenal humanitarian norms. Disinformaon opera-
ons aimed at humanitarian organizaons—alleging their cooperaon with people trackers, advancing ideological objec-
ves, or misappropriang funds—have eroded public faith in recognised humanitarian enes. The implicit social permission
that has always validated internaonal humanitarian intervenon is increasingly fractured and contested.
The rivalry amongst great powers has heightened the geopolical manipulaon of humanitarian aid. Levitsky, Zibla, and Da
Empoli all emphasise that the contest for spheres of inuence has transformed foreign aid into an instrument for exerng
so power. China has established an alternate paradigm of internaonal cooperaon that clearly dismisses requirements
pertaining to democrac governance or human rights. Russia has employed the provision and obstrucon of humanitarian
aid as a tool of geopolical leverage, especially in situaons like Syria and Ukraine. The instance of Israel restricng United
Naons access to Gaza exemplies how humanitarian aid is manipulated as a tool in polical negoaons, intenonally hin-
dering internaonal organisaons' ability to deliver essenal assistance in conict areas and employing humanitarian exigen-
cies as leverage within a larger geopolical framework.
The decline of mullateral organisaons like the United Naons—a trend idened by Levitsky and Zibla as associated with
the emergence of naonalist movements in Western democracies—has undermined the global coordinaon systems essen-
al for tackling transnaonal humanitarian issues such as mass displacement, pandemics, and
An addional challenge is the securisaon of humanitarian aid. When polical actors perceive their opponents as
"existenal enemies" rather than legimate competors, fundamental humanitarian issues—such as refugee protecon or
assistance to vulnerable populaons—become weapons in a broader cultural war.
This polarisaon has enabled the increasing securisaon of humanitarian aid, wherein humanitarian concerns are recontex-
tualised as risks to naonal security. The portrayal of migrants and refugees as possible terrorists or criminals typies this
phenomena. Da Empoli emphasises that digital strategists have methodically leveraged cultural and economic worries to
advance narraves that vilify humanitarian help, framing it as a threat to societal stability. Securisaon has substanal im-
plicaons for humanitarian organisaons. When governments priorise security measures over humanitarian concerns, they
enact restricve policies that signicantly hinder access to vulnerable communies. Simultaneously, humanitarian workers
encounter escalang legal dangers due to the criminalisaon of acts historically safeguarded by internaonal humanitarian
law, such aiding illegal migrants or delivering medical care in areas governed by non-state actors.
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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 erosion of public trust caused by decepon is a highly pernent topic. The proliferaon of fake news and conspiracy
theories has created an informaon environment where the truth becomes indiscernible and where any humanitarian inter-
venon can be portrayed as movated by hidden agendas.This phenomenon, which Da Empoli calls "algorithmic post-truth,"
has severely impacted humanitarian organizaons' ability to eecvely communicate both the needs they address and the
results they achieve. Coordinated disinformaon campaigns have spread narraves portraying NGOs as agents of foreign
interests, promoters of ideological agendas, or even secret trackers. The ability of malicious actors to exploit vulnerabilies
in the digital informaon ecosystem has made defending instuonal credibility a permanent challenge for the humanitarian
sector.
All these circumstances aect access to nancial support. In the polarised environment, humanitarian funding has become
simultaneously scarcer and more polically condioned. Naonalist rhetoric (" America First ", " Britain First ") that charac-
terises contemporary populist movements has legimized signicant reducons in internaonal cooperaon budgets, argu-
ing that naonal resources should be priorised over foreign needs. At the same me, available funds are increasingly sub-
ject to explicit or implicit polical condions. Tradional donors impose operaonal restricons aligned with geopolical or
naonal security objecves, compromising fundamental humanitarian principles such as neutrality and independence.
Technology manipulaon rises new ethical dilemmas in the modern humanitarian eorts. The growing digitalisaon of hu-
manitarian operaons—ranging from biometric idencaon of beneciaries to algorithmic assistance distribuon—
presents substanal problems in environments where personal data may be exploited for social control, surveillance, or po-
lical persecuon. As the Cambridge Analyca case demonstrates, the mass collecon of personal data carries signicant
risks when it occurs in environments with weak instuonal or legal protecons. Data collected for legimate humanitarian
purposes could potenally be seized or manipulated by authories with authoritarian tendencies. Humanitarian organiza-
ons thus face the dilemma of adopng technological innovaons that could signicantly improve their operaonal ecien-
cy, while navigang unprecedented ethical and praccal risks.
In summary, the works of Levitsky , Zibla , and Da Empoli provide an understanding of the depth and complexity of the
challenges facing internaonal humanitarian acon in the context of global democrac decline.
Confronted with this situaon, reimagining humanitarian eorts necessitates both praccal modicaons and strategic
reevaluaon. Humanitarian organisaons must culvate strong capabilies to funcon eecvely in adversarial instuonal
contexts, integrang advanced polical analysis into their strategic planning and employing adaptable methodologies that
enable rapid adjustment to evolving constraints. Simultaneously, they must enhance their resilience against disinformaon
operaons by invesng in strategic communicaon and fostering trust within local communies. A systemic reevaluaon of
the methods to reinforce the normave consensus typically supporng humanitarian acon is necessary. This involves ac-
knowledging that the safeguarding of humanitarian space is fundamentally connected to the defence of essenal democrac
principles: pluralism, autonomous instuons, condence in deliberave processes, and dedicaon to factual accuracy. In a
context where fundamental principles face systemac challenges, humanitarian intervenon cannot be seen independently
from the larger eorts to maintain democrac spaces.
Eventualy, safeguarding the imparality, independence, and ecacy of humanitarian eorts amid democrac decline neces-
sitates a fresh dedicaon to maintaining civic spaces, fostering eecve global frameworks, and construcng extensive coali-
ons that surpass polical divisions. The worldwide humanitarian society can only achieve its crical mandate through this
coordinated strategy.
We must also recognise that we are confronng the disintegraon of the world in which the majority of adults have lived,
together with numerous principles that characterised it. Democracies, as currently understood, are deteriorang, and nu-
merous ones are undergoing disintegraon. As a result, the humanitarian sector, with its principles of safeguarding at-risk
communies and fostering a more compassionate and equitable world, faces the threat of exncon. Global cizens must
recognise that naonal and internaonal policies aect their most inmate daily lives and arculate the world they wish to
bequeath to their children, as well as the acons they may undertake to create that desired reality. Indierence to reali-
ty seems dangerous and unacceptable.
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W A B I P N E W S L E T T E R P A G E 14
References
1. Da Empoli, G. (2019). Gli engineers of chaos . Marsilio Editori
2. Levitsky , S., & Zibla , D. (2018). How democracies die . New York, Crown Publishing,
3. El País. (2019). "The polarizaon of digital media." [Interview with Giuliano Da Empoli].
4. The Republic . (2019). " Interview with Giuliano Da Empoli".
5. Le Monde. (2019). " Comment Cambridge Analyca a changed the polics ."
6. Polical Europe . (2019). "Regulang Big Tech in the Digital Age."
7. The Financial Times. (2019). "The Dark Side of Digital Democracy."
8. The Guardian. (2019). "Authoritarian Leaders and Digital Manipulaon."
9. The New York Times. (2018). "How Democracies Die: A Warning from History."
10. UNHCR. (2020). "The Impact of Digital Disinformaon on Humanitarian Acon."
*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.
Best Image Contest 2025 (2 of 3)
Central Airway Diseases
Adenoid Cysc Carcinoma- tracheal tumor
Credits / Image courtesy of
Dr. Kona Lakshmi Chermisha Naidu
Best Image Contest
P A G E 15
This image is 2 of 3 selected among 100+ submissions to our Best Image Contest held in late 2023. Our next
Image Contest will open later this year. We look forward to receiving your image submissions.
P A G E 16
WABIP News
IP Fellowships 2026 Applicaons Now Open!
We cordially invite you to apply for an intensive Intervenon-
al Pulmonology fellowship program conducted by the WABIP
and Liv Hospital. This is open to pulmonologists and thoracic
surgeons worldwide, with new opportunies every three
months. The duraon of the program for each fellow is three
months, aligned with the following calendar year quarters:
Quarter 1: January 1 – March 31
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Quarter 3: July 1 – September 30
Quarter 4: October 1 – December 31
Applicaons are currently open for all quarters in 2026.
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Applicaons are due by June 15, 2025
Inving Applicaons for Prof. Levent Dalar Scholarship for IPI Fellows
We are pleased to invite applicaons for the Prof Levent Dalar IPI Scholarship, oering USD 5,000 each to two selected
fellows to support their parcipaon in the Intervenonal Pulmonology Internaonal (IPI)
program. Eligibility Criteria:
• Must be a resident of a country listed under the United Naons Least Developed Coun-
tries (LDCs).
• Currently employed at a public or academic/training instuon.
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their home country.
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Academic Collaboraon between AABIP and WABIP – IPI
The Intervenonal Pulmonology Instute (IPI) of the World Associaon for Bronchology and In-
tervenonal Pulmonology (WABIP) is proud to announce an academic collaboraon with the
American Associaon for Bronchology and Intervenonal Pulmonology (AABIP).
This collaboraon marks a signicant step forward in advancing global educaon and training in
intervenonal pulmonology. The AABIP has graciously supported the IPI’s educaonal mission
and cercaon processes by providing academic and cercaon materials developed by their
world-renowned faculty.
WABIP – IPI extends its sincere gratude to the AABIP for their generous support and shared
commitment to excellence in educaon, professional development, and internaonal cooperaon in the eld of inter-
venonal pulmonology.
Together, we look forward to shaping the future of our specialty and enhancing standards of care worldwide.
Standardizing the Standards
In the evolving landscape of pulmonary diagnoscs, the rise of advanced bronchoscopic techniques, such as roboc-assisted and navigaon bron-
choscopy, has ushered in a new era of promise in detecng and diagnosing lung nodules. However, despite the technological sophiscaon, one
crical issue connues to cloud the actual value of these innovaons: the inconsistent denion of diagnosc yield.
At the heart of this confusion lies the lack of consensus on what constutes a “yield” in a biopsy procedure. While most experts agree that diagnos-
c yield—the proporon of procedures resulng in a denive diagnosis—should be the primary outcome measure in diagnosc studies, the prac-
cal denions remain highly variable. Some denions consider non-specic inammatory or benign ndings diagnosc, while others adopt a
more conservave stance, requiring ssue results to inform paent management directly. This inconsistency, as highlighted in a recent study by
Vachani et al. (1), can create a staggering 20% dierence in reported yield across a cohort of 1,000 paents, depending on whether a strict, inter-
mediate, or liberal denion is applied.
This variability is not merely academic. It has signicant implicaons for paent care, technology adopon, and healthcare spending. The allure of
high-yield percentages can mislead clinicians and instuons into overesmang the eecveness of specic technologies. Moreover, studies
funded by corporate partners are parcularly vulnerable to adopng yield denions that inate apparent ecacy, compounding bias, and under-
mining objecve evaluaon.
Recognizing the urgency of this issue, a recent joint statement by the American Thoracic Society and the American College of Chest Physicians as-
sembled a muldisciplinary panel to propose a standardized, strict denion of diagnosc yield for advanced bronchoscopy (2). Their framework
emphasizes aconable outcomes that inform subsequent clinical management and categorizes non-specic or indeterminate results as non-
diagnosc. This structured approach aligns with the STARD (Standards for Reporng Diagnosc Accuracy Studies) guidelines and introduces a pro-
posed STARD-inspired ow chart tailored for advanced diagnosc bronchoscopy (2).
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
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
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Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
Ali Musani MD
Professor of Medicine and Surgery
Division Chief, Pulmonary Medicine
Director, Western Region Intervenonal
Pulmonology, Northwell Health
Lenox Hill Hospital
Abhinav Agrawal, MD, FCCP, DAABIP
System Director, Intervenonal Pulmonology,
Northwell Lung Instute
Director of Intervenonal Pulmonology &
Bronchoscopy (North Shore/LIJMC)
Associate Professor of Medicine
Associate Professor of Cardiovascular & Thoracic
Surgery
Division of Pulmonary, Crical Care & Sleep Medicine
Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell
Such standardizaon is long overdue. We can facilitate fair comparisons across technologies, centers, and study designs by ensuring trans-
parency and uniformity in reporng outcomes. The proposed denion sets a high bar for evidence, guarding against inated claims while
promong rigorous, paent-centered research.
Nevertheless, it is essenal to acknowledge that several confounding factors—such as disease prevalence, operator experience, and variabil-
ity in pathology interpretaon—can inuence outcomes even with a strict denion. A standardized denion is not a cure-all but a crical
step toward meaningful progress in evaluang diagnosc technologies.
As lung cancer screening becomes more widespread and advanced biopsy techniques expand, establishing a universal, unbiased denion of
diagnosc yield is essenal. Only then can we ensure accurate assessments, guide responsible technology adopon, and ulmately improve
paent outcomes.
References
1. Vachani A et al. Chest. 2022 May;161(5):1426–8.
2. Gonzalez AV et al. Am J Respir Crit Care Med. 2024 Mar 15;209(6):634–46.
Research
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WABIP ACADEMY- WEBCASTS
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
W A B I P N E W S L E T T E R
Links
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
surgeons.
www.jrs.or.jp The Japanese Respirology Society
sites.google.com/site/asendoscopiarespiratoria/
Asociación Sudamericana de Endoscopía Respiratoria
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