Multi-disciplinary team meetings for lung cancer in Norway and Denmark: results from national surveys and observations with MDT-MODe.

BACKGROUND AND PURPOSE: Multi-disciplinary Team (MDT) meetings are widely regarded as the 'gold standard' of lung cancer care. MDTs improve adherence to clinical guidelines for lung cancer patients. In this study, we describe and compare lung cancer MDTs in Denmark and Norway by combining national surveys and the MDT-Metric for the Observation of Decision-making (MDT-MODe) instrument. MATERIALS AND METHOD: Identical surveys were sent out to all lung cancer MDT centers in Denmark and Norway by the Danish Lung Cancer Group and the Norwegian Lung Cancer Group. Six MDT centers, three in Denmark and three in Norway, were observed using the MDT-MODe instrument. RESULTS AND INTERPRETATION: We found similar organization of MDT meetings in both countries, with the main difference being more local MDT meetings in Norway. All lung cancer MDTs were chaired by respiratory physicians and attended by a radiologist. Other members included oncologists, pathologists, thoracic surgeons, specialist nurses, nuclear medicine specialists and junior doctors. Overall, members reported that they had sufficient time for preparation and attending MDT meetings. With the MDT-MODe instrument it was found that the MDT chairs, surgeons, oncologists, radiologists all contributed positively to case discussion. Comorbidities were included in the discussion of most patients while the patient's view and psychosocial issues were less often discussed. A treatment decision was reached in 79.7% of cases discussed. In conclusion, we found similar settings and overall good quality concerning lung cancer MDT meetings in Denmark and Norway.

Consequences of Losing Incidental Pulmonary Nodules to Follow-Up: Unmonitored Nodules Progressing to Stage IV Lung Cancer.

INTRODUCTION: Lung cancer is the leading cause of cancer-related death globally. Incidental pulmonary nodules represent a golden opportunity for early diagnosis, which is critical for improving survival rates. This study explores the impact of missed pulmonary nodules on the progression of lung cancer. METHODS: A total of 4,066 stage IV lung cancer cases from 2019 to 2021 in Danish hospitals were investigated to determine whether a chest computed tomography (CT) had been performed within 2 years before diagnosis. CT reports and images were reviewed to identify nodules that had been missed by radiologists or were not appropriately monitored, despite being mentioned by the radiologist, and to assess whether these nodules had progressed to stage IV lung cancer. RESULTS: Among stage IV lung cancer patients, 13.6% had undergone a chest CT scan before their diagnosis; of these, 44.4% had nodules mentioned. Radiologists missed a nodule in 7.6% of cases. In total, 45.3% of nodules were not appropriately monitored. An estimated 2.5% of stage IV cases could have been detected earlier with proper surveillance. CONCLUSION: This study underlines the significance of monitoring pulmonary nodules and proposes strategies for enhancing detection and surveillance. These strategies include centralized monitoring and the implementation of automated registries to prevent gaps in follow-up.

Four different models for simulation-based training of bronchoscopic procedures.

BACKGROUND: Flexible bronchoscopy procedures require detailed anatomical knowledge and advanced technical skills. Simulation-based training offers a patient-safe training environment that can be more efficient than patient-based training. Physical models are cheaper than virtual reality simulators and allow trainees to be acquainted with the equipment used in the clinic. The choice of a physical model for training depends on the local context. The aim of this study was to compare four different bronchoscopy models for flexible bronchoscopy training. METHODS: The BronchoBoy manikin, the Koken manikin, a human cadaver, and a preserved porcine lung were included in the study. Seven physicians experienced in bronchoscopy performed a bronchoscopic airway inspection, bronchoalveolar lavage (BAL), and tissue sampling on all four models with performance evaluated by observation and participant evaluation of models by questionnaire. RESULTS: Nineteen segments were identified in all human anatomy models, and the only significant difference found was that only the Thiel embedded cadaver allowed all participants to enter RB1 with an instrument in the working channel (p = 0.001). The Thiel embedded cadaver and the BronchoBoy manikin had low fluid return on BAL (22 and 52 ml), whereas the Koken manikin and the preserved porcine lung had high return (132 and 134 ml), (p = 0.017). Tissue samplings were only completed in the preserved porcine lung and the Thiel embedded cadaver (p < 0.001). CONCLUSIONS: An anatomically correct bronchoscopy is best simulated with the Koken manikin or the Thiel embedded cadaver. Bronchoalveolar lavage should be simulated with the Koken manikin or the preserved porcine lung. Tissue sampling procedures are best simulated using the Thiel embedded cadaver or the preserved porcine lung.

Endobronchial Ultrasound for the Screening of Pulmonary Embolism in Patients with Suspected Lung Cancer: A Prospective Cohort Study.

BACKGROUND: Patients with lung cancer exhibit increased risk of pulmonary embolism (PE). While the contrast phase of computed tomography of the chest in the diagnostic work-up of suspected chest malignancy does not allow reliable detection of PE, it may be feasible to screen for present PE during endobronchial ultrasound (EBUS) examination. OBJECTIVES: The aim of this study was to establish if screening during EBUS for PE in patients with suspected lung cancer is feasible and if positive findings are predictive of PE. METHODS: Patients undergoing EBUS due to suspicion of malignancy of the chest were prospectively enrolled. The pulmonary arteries were assessed during EBUS using a standardized protocol. Patients in whom PE suspicion was raised were referred to confirmatory imaging. RESULTS: From December 2020 to August 2021, 100 patients were included. Median time for vascular assessment during EBUS was 2 min (Q1-Q3: 1-3 min). EBUS identified two suspected PEs (2%), and the number needed to scan was 50. The positive predictive value of EBUS for PE was 100%. CONCLUSION: EBUS for PE screening seems feasible and with limited time use. The PPV of positive findings for the diagnosis of PE is high, but the utility is somewhat limited by a high number needed to scan even in a high-risk population. Based on our findings, we believe that EBUS assessment of the pulmonary vasculature may have a role as a routine screening tool for PE. The assessment for PE should be implemented in EBUS training programmes, as operators should be able to recognize incidental PEs.

Does the Addition of Radial Endobronchial Ultrasound Improve the Diagnostic Yield of Electromagnetic Navigation Bronchoscopy? A Systematic Review.

BACKGROUND: Lung cancer is the leading cause of cancer-related death worldwide. Early diagnosis is crucial to increased survival rates. Radial endobronchial ultrasound (rEBUS) and electromagnetic navigation bronchoscopy (ENB) have been developed for the diagnosis of small lung lesions. The aim of this systematic review was to evaluate whether the combination of rEBUS and ENB is superior to ENB alone. METHOD: A systematic search was performed using MEDLINE, Embase, and Cochrane Library databases on "ENB," and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The project was registered with PROSPERO, number CRD42020214682. RESULTS: In total, 2,092 studies were identified through a literature search. Five studies were included in the final review. One study found that the addition of rEBUS increased diagnostic yield, while another concluded the converse. Three studies did not have significant results. Meta-analysis was not feasible due to heterogeneity and the small number of studies. CONCLUSION: As the current evidence on the topic is sparse and heterogeneous, it is not possible to conclude whether the addition of rEBUS to ENB has a significant impact on diagnostic yield. Further studies are needed to illuminate this question in order to ensure optimal choice of endoscopic technique as well as used time and resources. The project received funding from the Region of Southern Denmark's PhD fund.

Ensuring Basic Competence in Thoracentesis.

BACKGROUND: Trocar pigtail catheter thoracentesis (TPCT) is a common procedure often performed by junior physicians. Simulation-based training may effectively train physicians in the procedure prior to performing it on patients. An assessment tool with solid validity evidence is necessary to ensure sufficient procedural competence. OBJECTIVES: Our study objectives were (1) to collect evidence of validity for a newly developed pigtail catheter assessment tool (Thoracentesis Assessment Tool [ThorAT]) developed for the evaluation of TPCT performance and (2) to establish a pass/fail score for summative assessment. METHODS: We assessed the validity evidence for the ThorAT using the recommended framework for validity by Messick. Thirty-four participants completed two consecutive procedures and their performance was assessed by two blinded, independent raters using the ThorAT. We compared performance scores to test whether the assessment tool was able to discern between the two groups, and a pass/fail score was established. RESULTS: The assessment tool was able to discriminate between the two groups in terms of competence level. Experienced physicians received significantly higher test scores than novices in both the first and second procedure. A pass/fail score of 25.2 points was established, resulting in 4 (17%) passing novices and 1 (9%) failing experienced participant in the first procedure. In the second procedure 9 (39%) novices passed and 2 (18%) experienced participants failed. CONCLUSIONS: This study provides a tool for summative assessment of competence in TPCT. Strong validity evidence was gathered from five sources of evidence. A simulation-based training program using the ThorAT could ensure competence before performing thoracentesis on patients.

Endoscopic ultrasound-guided fine-needle aspiration using the bronchial ultrasound scope (EUS-B-FNA) for diagnosing pancreatic metastasis in a lung cancer patient case report.

Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) of the pancreas is performed routinely in many endoscopic centers as part of the diagnostic set-up for suspected pancreatic cancer. The use of transesophageal bronchoscopic ultrasound-guided fine needle aspiration (EUS-B-FNA) by pulmonologists has expanded significantly, since it enables effective diagnosis of lesions in the mediastinum and upper abdomen. The following case demonstrates the safety and feasibility of EUS-B-FNA in a patient with non-small cell lung cancer (NSCLC) cancer and a pancreatic mass of unknown origin. A patient who was previously diagnosed with NSCLC was referred to the Department of Respiratory Medicine, Odense University Hospital due to suspected recurrence of NSCLC. The patient underwent endobronchial ultrasound guided (EBUS)-FNA from several suspected mediastinal lymph nodes and combined EUS-B-FNA from a pancreatic mass during the same procedure. Pathology results from the pancreatic mass and from the mediastinal lymph nodes showed squamous-cell carcinoma, metastasis from the previous NSCLC. We here by demonstrated that EUS-B-FNA is a feasible and safe technique to obtain tissue samples from pancreatic lesions in patients under investigation for lung cancer.

Advances in the diagnosis and follow-up of pleural lesions: a scoping review.

INTRODUCTION: Pleural lesions may have heterogeneous presentation and causes. In recent years, there have been significant advances in pleural lesions diagnostics. The aim of this review is to provide an overview of the state-of-the-art, and recent updates for diagnostic modalities and monitoring regimes for pleural lesions. AREAS COVERED: A literature search was conducted through PubMed and Web of Science for relevant articles published from 1 January 2000- 1 March 2023. This article critically appraises the radiological modalities and biopsy techniques that are employed in pleural lesions diagnostics, including chest radiography, thoracic ultrasound, computed tomography, F-fluorodeoxyglycose positron emission tomography, magnetic resonance imaging, percutaneous, and thoracoscopic pleural biopsies with reference to their strengths, limitations, and clinical use. The review asserts also the available literature regarding monitoring algorithms. EXPERT OPINION: Despite the recent advances in the field, there are several key areas for improvement, including the development and validation of minimal invasive methods and tools for risk stratification, the integration of multi-omics technologies, the implementation of standardized, evidence-based diagnostic and monitoring guidelines and increased focus on research and patient-centric approaches. The broad establishment of dedicated pleural clinics may significantly assist toward this direction.

Bronchoscopic procedures to diagnose peripheral lung lesions.

Bronchoscopy has a low risk of complications when diagnosing peripheral lung lesions suspected of malignancy, however the procedures do not always determine a diagnosis. Several modalities have been invented to improve the diagnostic yield, including radial endobronchial ultrasound and electromagnetic navigation, which are currently used by several departments in Denmark. Augmented fluoroscopy, CT-guided bronchoscopy and robotic bronchoscopy are not yet available in Denmark, but may improve the diagnostic work-up, as argued in this review.

Management of incidental pulmonary nodules in CT examination.

Lung cancer is the leading cause of cancer-related death in Denmark and the world. The increase in CT examinations has led to an increase in detection of pulmonary nodules divided into solid and subsolid (including ground glass and part solid). Risk factors for malignancy include age, smoking, female gender, and specific ethnicities. Nodule traits like size, spiculation, upper-lobe location, and emphysema correlate with higher malignancy risk. Managing these potentially malignant nodules relies on evidence-based guidelines and risk stratification. These risk stratification models can standardize the approach for the management of incidental pulmonary findings, as argued in this review.