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William Krimsky



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    MA13 - Interventional Pulmonology (ID 914)

    • Event: WCLC 2018
    • Type: Mini Oral Abstract Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/25/2018, 10:30 - 12:00, Room 206 AC
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      MA13.09 - Electromagnetic Navigation Bronchoscopy as an Integrated Approach to Aid in Diagnosis and Treatment of Pulmonary Lesions (ID 12623)

      11:30 - 11:35  |  Author(s): William Krimsky

      • Abstract
      • Presentation
      • Slides

      Background

      Electromagnetic navigation bronchoscopy (ENB) is an image-guided localization approach to guide endoscopic tools to lung targets. In a single procedure, ENB aids in localizing lung lesions for biopsy or molecular profiling, fiducial placement for stereotactic body radiation therapy (SBRT), or dye marking for surgical resection. The multidisciplinary utility of ENB in a large, prospective, multicenter study is unknown.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      NAVIGATE (clinicaltrials.gov, NCT02410837) is a prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. From April 2015 to August 2016, 1,215 consecutive subjects were enrolled at 29 United States sites. Two-year follow-up is ongoing. A prespecified 1-year interim analysis is presented.

      4c3880bb027f159e801041b1021e88e8 Result

      ENB was used to aid in lung lesion biopsy (n=1157 subjects), fiducial placement (n=258), pleural dye marking (n=23), and/or lymph node biopsy (n=30). EBUS-guided lymph node staging was conducted in the same procedure in 448 subjects. The median lesion-to-pleura distance was 9mm. The median lesion size was 20mm; most were in the middle (30%) and peripheral (67%) thirds of the lung. Pathology results were malignant in 44.3% (484/1092) (54.1% Stage I, 11.1% Stage II, 17.0% Stage III, 17.7% Stage IV). Molecular testing was attempted in 30.7% (80/261) of adenocarcinoma or NSCLC-not-otherwise-specified cases overall and 57.9% (33/57) of Stage IIIB/IV cases. Tissue was adequate in 87.5% (70/80) of cases. EGFR mutations (14.7%) and ALK translocations (4%) were the most frequently observed genetic alterations. The ENB procedure was well-tolerated; 2.9% of subjects had procedure-related pneumothorax requiring hospitalization or intervention, lower than published rates for CT-guided core biopsy (25%) and CT-guided fine needle aspiration (19%). Subject-reported impact of ENB on daily activities was 0.9 out of 10 (0 = no impact).

      8eea62084ca7e541d918e823422bd82e Conclusion

      In the largest prospective, multicenter study to date, ENB aided in lesion biopsy in the middle and periphery of the lung and tissue collection for molecular testing, with a very low morbidity. ENB facilitates a multidimensional approach to lung biopsy and mediastinal/hilar staging, offering the opportunity for multiple sites/tissues to be safely sampled in one anesthetic event.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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    P1.05 - Interventional Diagnostics/Pulmonology (Not CME Accredited Session) (ID 937)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
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      P1.05-06 - Bronchoscopic Image-Guided Microwave Ablation of Peripheral Lung Tumours – Early Results (ID 14420)

      16:45 - 18:00  |  Author(s): William Krimsky

      • Abstract
      • Slides

      Background

      Thermal ablation is indicated for the treatment of early lung cancer in medically inoperable patients, and for oligometastatic disease. However, percutaneous ablation is associated with 30-50% pneumothorax, haemothorax, pleural effusion and pain. Peripheral lung tumours can be reached by electromagnetic navigation bronchoscopy (ENB) without breaching the pleura. Intraprocedural cone-beam CT (CBCT) and transbronchial access instruments allow lesions in the lung periphery to be reached with accuracy. Another advantage of the bronchoscopic approach is the ability to concurrently obtain tissue for diagnosis and molecular characterization, and to perform full nodal staging.

      Bronchoscopic radiofrequency ablation (RFA) has been described for tumours with positive bronchus sign, but the effectiveness of RFA is limited by impedence of air and heat-sink effects of vessels. Microwave avoids these limitations.

      We present our early experience of bronchoscopic microwave ablation of tumours with CBCT guidance and transbronchial access.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      ENB (Superdimension, Medtronic, Minneapolis) was carried out under general anaesthesia. A CBCT (Philips, Eindhoven) confirms probe position and its relationship to the lesion. Transbronchial access with CrossCountry device (Medtronic, Minneapolis) was used as required to reach extrabronchial lesions. A flexible microwave ablation catheter (Emprint, Medtronic) was advanced to the lesion. Ablation was planned with OncoSuite (Philips, Eindhoven) to ensure the ablation zone encompassed the lesion with a 5mm margin. Ablation was carried out and a fiducial was placed at the ablation site to facilitate follow-up. A control CBCT was carried out post procedure.

      4c3880bb027f159e801041b1021e88e8 Result

      Between February and April 2018, three patients (2F:1M, mean age 70.3) with oligometastatic disease (2 colorectal, 1 endometrial) underwent bronchoscopic microwave ablation to 4 lung lesions (two RLL nodules (in one patient), LUL and LLL, median size 10.5mm (range 7-13mm), 3 without bronchus sign). All lesions were reached, with the LUL nodule requiring transbronchial access. All lesions were treated at 100W for 10 minutes.

      CBCT confirmed ground-glass opacification of the ablation zones encompassing the lesions. There were no procedural complications, pneumothorax or bleeding. Two patients with lesions close to the pleura experienced mild, localised chest discomfort which resolved by 24 hours. All patients were discharged the following day. A CT at 30 days for the first patient showed a 25x32mm area of dense ovoid consolidation representing the ablation zone, with no complications.

      8eea62084ca7e541d918e823422bd82e Conclusion

      Our early experience shows bronchoscopic microwave ablation is safe and feasible with low morbidity. The accuracy of the procedure is enhanced by CBCT control. Lesions remote from the bronchial tree could be accessed and safely treated.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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