Volume 12
Issue 02
June 2024
Inside This Issue
Editorial, 2-4
Technology Corner, 5-6
Tips from the Experts, 7-9
Humanitarian News, 10-15
Best Image Contest, 16
WABIP News, 17
Research, 18-19
Links, 20
Future of EBUS-TBNA – EBUS-Plus
WABIP Newsletter
J U N E 2 0 2 4 V O L U M E 1 2 , I S S U E 2
EXECUTIVE BOARD
Stefano Gasparini, MD
Italy, Chair
Pyng Lee, MD, PhD
Singapore, Vice-Chair
Hideo Saka, MD
Japan , Immediate Past-
Chair
Silvia Quadrelli, MD
Membership Commiee
Chair
Jean-Michel Vergnon, MD
Educaon Commiee
Chair
Ali Musani, MD
Finance Commiee Chair
Naofumi Shinagawa, MD
Japan,
Secretary General
Menaldi Rasmin, MD, PhD
Indonesia , President
WCBIP 2024
Rajesh Thomas, MD, PhD
Melbourne , President
WCBIP 2026
STAFF
Michael Mendoza
General Manager
Judy McConnell
Administrator
Kazuhiro Yasufuku
Newsleer Editor-in-chief
P A G E 2
From the publicaon of the landmark study in 2004,
[1] Endobronchial ultrasound-guided transbronchial
needle aspiraon (EBUS-TBNA) has transformed the
landscape of Respiratory Medicine and been the key
driver in the rapid expansion of the eld of Interven-
onal Pulmonology. Variably performed by pul-
monologists and thoracic surgeons, the procedure
has become the standard of care in minimally inva-
sive assessment of intrathoracic lesions, and an in-
dispensable tool in a lung cancer muldisciplinary
service. In considering what the future pracce of
EBUS-TBNA may look like, it is worth reviewing the
progress from the me of introducon to the cur-
rent landscape in performance of EBUA-TBNA.
Following demonstraon of safety and diagnosc
accuracy of EBUS-TBNA , mulple randomized stud-
ies demonstrated comparable diagnosc accuracy to
surgical mediasnoscopy,[2, 3] which was previous-
ly the standard approach for pre-operave medias-
nal lymph node staging. This resulted in EBUS-TBNA
being recommended in internaonal clinical pracce
guidelines as the preferred technique for medias-
nal lymph node staging in non-small cell lung cancer
(NSCLC). The success of EBUS-TBNA is reected in
real-world data demonstrang the dramac drop in
the number of mediasnoscopy procedures per-
formed.[4, 5]
From this point, advances in EBUS-TBNA were not
based on changes to the technique, but to doing
more ulising the same technique. This included
sampling of centrally posioned parenchymal tu-
mours, sarcoid, and isolated mediasnal/hilar lym-
phadenopathy, with high accuracy demonstrated for
various pathologies including extra-thoracic malignancy,
lymphoma and sarcoid.[6-8]
Subsequently, EBUS-TBNA began to be ulized not just for
diagnosc sampling, but for systemac mediasnal LN stag-
ing in NSCLC. Surgical guidelines had recognized the im-
portance of comprehensive lymph node staging in NSCLC,
with registry data indicang a likely survival advantage with
more complete intra-operave staging. Mulple studies
conrmed the ability of EBUS-TBNA to detect PET-occult
metastases in paents with early stage NSCLC, and in 2015
the joint ERS/ESTS guidelines recommended all paents
with early stage NSCLC with features associated with a
higher risk of post-operave nodal upstaging (any of T2,
cN1 or central tumour) undergo systemac mediasnal
staging with EBUS-TBNA.[9] Most recently, the SEISMIC
study conrmed the clinical ulity of EBUS-TBNA in a new
paent group: those with Locally Advanced NSCLC (LA-
NSCLC).[10] This landmark internaonal study detailed the
clinical impact of systemac mediasnal nodal staging to
most accurately inform radiaon eld planning in paents
with LA-NSCLC. Ulity of systemac mediasnal staging
(rather than targeted diagnosc sampling) is best demon-
strated by the primary study outcome; detecon by EBUS-
TBNA of PET occult LN metastases in 12% of parcipants. In
silico radiaon planning conrmed an extremely low radia-
on dose to most sites of PET occult disease,[10] idenfying
an extremely high likelihood of disease relapse in the 12%
of paents in whom PET-occult disease was detected by
EBUS-TBNA.
The paern I see in the recent advancement of EBUS-TBNA
is of an increasingly methodical approach to sampling of
mediasnal and hilar structures to the point where now
systemac mediasnal staging should be considered the
Daniel Steinfort (MBBS, BMedSci, FRACP, PhD)
Respiratory Physician, Dept Respiratory Medicine, RMH
Head, Intervenonal Pulmonology Service, RMH
Respiratory Physician, Dept Cancer Medicine,
Peter MacCallum Cancer Centre
Principal Research Fellow, Dept Medicine (RMH),
University of Melbourne
W A B I P N E W S L E T T E R
P A G E 3
PET-occult LN metastases, and the high number of “normal”
lymph nodes (>2 in a majority of paents – unpublished da-
ta) sampled.
In tension with the desire to complete thorough medias-
nal/hilar LN evaluaon is the need to dene sampling crite-
ria to manage resource ulizaon and prevent procedure
mes extending unreasonably. Certainly, should a novel thin
convex probe videobronchoscope, previously reported in ex
vivo human models to allow assessment of almost all seg-
mental bronchii and even cytologic sampling of subsegmen-
tal LN,[17] become available, it is unlikely to be feasible to
perform as extensive sampling as this instrument will per-
mit. There may be a point where future of EBUS in some
areas may now be to begin more selecve targeng of LN. It
remains to be established exactly what extent of LN sam-
pling should be performed in paents with NSCLC undergo-
ing “systemac” mediasnal evaluaon – should procedur-
alists rounely sample all 5 mediasnal staons or should
systemac evaluaon with EBUS be followed only by limited
sampling with TBNA, perhaps based on probability of meta-
stac involvement (eg. Canada Lymph Node Score[18])?
Alternavely, in paents with cN0-2, perhaps an approach
analogous to surgical R-staging (ensuring at least one
“normal” LN at a higher echelon than the highest patholog-
ic/PET-posive LN is sampled – avoiding R(un)).[19] Equally,
is evaluaon of contralateral hilar LN necessary when the
detecon rate of PET-occult metastases is just 1%?[12] As
an illustraon of this challenge, the number of LN sampled
during “systemac” mediasnal staging varies widely be-
tween reports from just one, to as high as eight.[20]
Beyond opmal pathways for performance of EBUs-TBNA,
the elegance and technical simplicity of the convex probe
scope will also allow expansion of minimally invasive tech-
niques, especially in combinaon with novel technologies/
tools. Already, mediasnal cryobiopsy has been demonstrat-
ed in randomised studies to provide superior diagnosis to
EBUS-TBNA in lymphoma.[21-23] Notably, while some au-
thors have suggested EBUS-cryobiopsy may be more eec-
ve in achieving molecular evaluaon in NSCLC,[23] there
are sucient reports to suggest that obtaining adequate
cellularity [24, 25] and improvements to specimen handling/
processing may achieve the same outcomes. To illustrate
what can be achieved with EBUS-TBNA specimens, one large
mul-centre study reported ability to perform whole ge-
nome sequencing using EBUS specimens in approximately
half of 220 cases.[26] This highlights the importance not just
of connued technical progression, but of ensuring opmal
performance of techniques already well established, as dis-
cussed above.
current standard of care in management of NSCLC.
Is there sll further for EBUS-TBNA to advance?
Looking to the future, advances in EBUS-TBNA are
likely to fall into one of two categories; rstly the
excing idea of incorporaon of novel techniques/
technologies, and ; secondly the less exhilarang
but possibly more impacul advance of more con-
sistent and opmal use of EBUS-TBNA in assessing
paents with NSCLC.
ERS/ESTS as noted above recommend pre-
operave systemac mediasnal nodal staging in
paents with T2/cN1/centrally posioned tumours.
[9] This previously was predicated on the potenal
for upstaging by EBUS-TBNA to N2 disease which
may result in non-surgical management being pre-
ferred. Recent advances in immune checkpoint
inhibitor (ICI) therapy now also emphasize the rou-
ne sampling of hilar LN in addion to mediasnal
staons. Mulple RCTs demonstrate a survival ad-
vantage for paents with Stage IIA-III receiving
neoadjuvant ICI,[11] emphasizing the importance
of thorough evaluaon of hilar (and even intra-
pulmonary where possible) LN. Therefore, as rec-
ommended in the recently published WABIP expert
panel consensus statement on proposed quality
indicators for EBUS,[12] all paents with Stage Ib-
IIIA NSCLC should be considered for systemac
staging with EBUS-TBNA.
The eld of implementaon science exists to ad-
dress the consistent gap between what evidence
suggests is opmal care, and what is rounely per-
formed day-to-day. Reducing variance in care is an
eecve low-cost way to signicantly improve de-
livery of care for our paents. Anecdotally, system-
ac staging is inconsistently performed except in
jurisdicons where it is mandated. Notably, moni-
toring of quality has been demonstrated to im-
prove performance of EBUS and idenfy specic
areas for aenon.[13, 14] This endeavour remains
a key challenge in the future of EBUS-TBNA. In-
creasing the proporon of paents with Stage Ib-
!!!A NSCLC undergoing systemac staging will be a
key challenge in the future of EBUS-TBNA to ensure
consistent opmal care. Future work in prospec-
vely embedding this pracce is required, and may
involve some changes to current pracce. For ex-
ample, synopc procedural reporng is ulized in
endoscopic procedures to ensure opmal quality of
procedures.[15, 16] Synopc reporng was ulised
in the SEISMIC study and may have been a contrib-
ung factor to the signicant rate of detecon of
W A B I P N E W S L E T T E R
P A G E 4
22. Fan Y et al. Lancet Respir Med, 2023. 11(3): p. 256-264.
23. Ariza-Prota, M et al. ERJ Open Res, 2023. 9(2).
24. Hendry S et al. Cytopathology, 2020. 31(2): p. 90-95.
25. Vuorisalo A et al. Diagn Cytopathol, 2024. 52(5): p. 271-287.
26. Fielding, D et al. Cancers (Basel), 2024. 16(4).
27. Ishiwata T et al. J Thorac Cardiovasc Surg, 2022. 164(4): p.
1188-1197 e2.
It is likely that therapeuc intervenons will com-
prise some of the future of Convex probe EBUS.
Already, clinical trials have reported use of a nee-
dle-type radiofrequency ablaon probe delivered
via EBUS videobronchoscope, to achieve ablaon
zones of up to 2.1cm.[27] With appropriate cryo-
gens, cryoablaon may also be possible with cry-
oprobes narrow enough to be deployed via the
EBUS scope.
In conclusion, the tool that has been the corner-
stone of IP for two decades will almost certainly
remain so well into the future. Renements in
techniques as well as tools will drive progress, un-
derpinned by a strong evidence base supplied by
well-conducted studies. This has long been a
strength in IP/EBUS-TBNA and we will all be able to
cra the future of EBUS-TBNA through further rig-
orous studies and development of novel ideas. And
all to the benet of our paents.
References:
1. Yasufuku K et al. Chest, 2004. 126(1): p. 122-8.
2. Annema JT et al. JAMA, 2010. 304(20): p. 2245-52.
3. Sharples LD et al. Health Technol Assess, 2012. 16
(18): p. 1-75, iii-iv.
4. Wahidi MM et al. Respiraon, 2023. 102(7): p. 495-
502.
5. Bousema JE et al.. Eur Respir J, 2021. 57(4).
6. Steinfort DP et al. J Thorac Oncol, 2010. 5(6): p. 804-
9.
7. Crombag LMM et al. Respirology, 2022. 27(2): p. 152-
160.
8. Steinfort DP et al. Intern Med J, 2011. 41(12): p. 815-
24.
9. Vilmann P et al. Eur Respir J, 2015. 46(1): p. 40-60.
10. Steinfort DP et al. Lancet Respir Med, 2024.
11. Banna GL et al. JAMA Netw Open, 2024. 7(4): p.
e246837.
12. Steinfort DP et al. Respirology, 2023. 28(8): p. 722-
743.
13. Punjabi A et al. BMJ Open Respir Res, 2021. 8(1).
14. Evison M et al. Thorax, 2016. 71(8): p. 762-3.
15. Johnson G et al. Surg Endosc, 2022. 36(5): p. 2886-
2895.
16. Roy H et al. Cureus, 2024. 16(2): p. e54480.
17. Patel P et al. Ann Thorac Surg, 2017. 103(4): p. 1158
-1164.
18. Sullivan KA et al. J Thorac Cardiovasc Surg, 2023.
19. Yun JK et al. J Thorac Oncol, 2021. 16(5): p. 817-826.
20. Serra Mitja P et al. Arch Bronconeumol, 2022.
21. Zhang J et al. Eur Respir J, 2021. 58(6).
W A B I P N E W S L E T T E R
P A G E 5
Technology Corner
Spray Cryotherapy for Management of Central Airway Obstrucon
Introducon
Spray cryotherapy (SCT) is an evolving therapeuc modality in the management of central airway obstrucon (CAO), that leverages
the physical properes of liquid nitrogen to achieve therapeuc outcomes. This arcle provides an overview of SCT, focusing on the
liquid nitrogen spray physics, its advantages over hot therapies, the underlying principles, cryobiology, and the available clinical evi-
dence. Central airway obstrucon can signicantly impair quality of life and increase morbidity in paents. Tradional management
strategies have included mechanical debulking, thermal ablaon, and stenng. However, these methods are associated with signi-
cant complicaons and limitaons. SCT emerges as a promising alternave, oering unique advantages in treang both benign and
malignant airway obstrucons.
Background
Tradional CAO treatments such as mechanical debulking and thermal ablaon oen lead to reparave healing, characterized by
scar formaon, which can compromise airway funconality due to the non-elasc nature of scar ssue. In contrast, SCT facilitates a
regenerave healing process, promising a return of funconal, structurally similar ssue with minimal scarring.
Liquid nitrogen, the working agent in SCT, exhibits remarkable physical characteriscs that are leveraged for therapeuc benet. At
atmospheric pressure, liquid nitrogen has a boiling point of -196°C, allowing it to rapidly absorb heat upon contact with the airway
ssue. This rapid cooling eect leads to instant freezing of the targeted lesions, causing intracellular ice formaon, cell membrane
rupture, and ulmately cell death through apoptosis. Unlike thermal ablaon, which causes widespread thermal injury and inam-
maon, the applicaon of liquid nitrogen results in a focused area of necrosis in high water content cells (broblast, tumor, granula-
on) while preserving the low water content basement membrane of carlage, collagen and elasn..
Moreover, the ability of SCT to achieve deep ssue penetraon while minimizing collateral damage is a direct result of the thermal
conducvity and the latent heat of vaporizaon of liquid nitrogen. These physical properes ensure that the cryogenic eect is local-
ized to the target area, reducing the risk of unintended ssue injury. The controlled and reversible nature of the freeze-thaw cycle
employed in SCT further disnguishes it from other thermal ablaon techniques, oering a tailored approach to managing airway
obstrucons based on the size, locaon, and nature of the lesion.
Os B Rickman, DO, FCCP, DAABIP
Ascension Saint Thomas Chest and Lung
Center
Professor, University of Tennessee
Health Sciences Center
W A B I P N E W S L E T T E R
P A G E 6
Clinical Applicaon
Spray cryotherapy (SCT) is ulized in various clinical sengs, from managing benign condions like airway stenosis to treang malig-
nant obstrucons due to advanced lung cancer. The adopon of advanced technologies, such as the third-generaon truFreeze Sys-
tem, has facilitated precise control over the spray, enabling uniform applicaon and enhancing procedural safety (Benn and Krishna,
2019).
Procedural Technique: The SCT procedure involves the bronchoscopic delivery of liquid nitrogen through a specially designed cathe-
ter directly to the lesion within the airway. The process begins with the paent under sedaon or general anesthesia, followed by the
inseron of the bronchoscope into the airway. 1ml of LN2 will expand to 700ml of gas, it is therefore imperave that there is an ade-
quate path for the gas to egress. This can be accomplished by using a rigid bronchoscope, LMA or 8.5 endotracheal tube. The cryo-
therapy catheter is then advanced through the working channel of the bronchoscope and extends 2cm. The anesthsia circuit is dis-
connected, if using an ETT the cu is deated and if rigid all ports opened. Upon acvaon, liquid nitrogen is sprayed in a controlled
manner, rapidly freezing the target ssue typical for 5-10 seconds. This freezing causes the cells to undergo apoptosis, leading to a
reducon in the obstrucon without signicant damage to the surrounding healthy ssue. The number and length of freeze-thaw
cycles are tailored to the specic characteriscs of the obstrucon and the paent's overall condion. It is important to note that
spray cryotherapy will cause edema and should not be used alone to restore patency for crical airway stenosis, as the edema from
the procedure could cause a temporary worsening of air ow.
Complicaons, while possible, are less frequent compared to other intervenons for airway obstrucon and include transient hypox-
emia, bradycardia, barotrauma (pneumothorax & pneumomediasnum) and rarely gas embolism. However, the procedural tech-
nique's renement and advancements in technology have contributed to a signicant reducon in adverse outcomes, arming SCT
as a safe and eecve opon for paents with central airway obstrucons (Finley et al., 2012).
Conclusions
SCT represents a signicant advancement in the management of central airway obstrucon. The physical characteriscs of liquid ni-
trogen—namely its low boiling point, rapid phase transion, and ecient heat absorpon—underpin the therapeuc ecacy of SCT.
Its ulity in creang a favorable healing environment, coupled with a relavely low complicaon rate, underscores its potenal as a
preferred method in suitable paents. As the technology and clinical experience with SCT connue to evolve, it is poised to occupy a
more central role in the therapeuc armamentarium against central airway obstrucon.
References
1. Kheir F et al. Chest. 2016;150(4):1141-1146.
2. Finley DJ et al. Ann Thorac Surg. 2012;94(1):199-204.
3. Benn B et al. J Thorac Dis. 2019;11(2):E1-E4.
4. Ratwani AP et al. J Bronchol Interv Pulmonol. 2023.
5. Moore RF et al. J Thorac Dis. 2017;9(2):E150-E155.
Tips from the Experts
P A G E 7 V O L U M E 1 2 , I S S U E 2
Introducon:
Intervenonal pulmonology employs numerous techniques to address airway disorders. Electrocautery is a form of contact-based electro-
surgery, which uses thermal ablave energy to destroy obstrucng ssue and provide hemostasis in the treatment of malignant and non-
malignant airway disorders accessible within the territory of exible and rigid bronchoscopy. Non-contact electrosurgery includes argon
plasma coagulaon (APC) and laser therapy, which have similar principles to electrocautery, but are not addressed in this arcle.
Electrocautery under the umbrella of electrosurgery causes an eect through the creaon of heat via a high-frequency alternang electrical
current. Tissue eects include: cung through vaporizaon, coagulaon, and fulguraon, which is the destrucon of ssue specically relat-
ed to heat caused by electricity. The thermal eect on ssue increases with the amount of electrical current applied, the resistance of the
ssue contacted, and is inversely proporonal to the contact area of the probe.
1
This form of electrocautery diers from direct current elec-
trocautery in which electricity is passed through a metal resistor to generate heat that is then conducted into ssue to create a coagulave
burn.
2
While electrocautery techniques have been employed for nearly a century,
3
the oxygen-rich environment of the airways bronchoscopists
operate within necessitates parcular safety consideraons to prevent combuson and airway res.
Indicaons:
The two primary indicaons for electrocautery are for treatment of central airway lesions and hemorrhage. While the exact incidence of
central airway obstrucon (CAO) is unknown, up to 30% of paents with lung cancer experience complicaons of CAO.
4
Following interven-
ons such as electrocautery, 48% of paents report improvement in symptoms.
5
A combinaon of electrosurgical techniques including direct contact in the form of electrocautery and non-contact in the form of argon plas-
ma coagulaon have been shown to eecvely treat CAO and negate the need for more expensive tools, such as the Nd-Yag laser.
6
Airway hemorrhage can be either spontaneous or iatrogenic. For paents with bleeding lesions that are visible to and accessible by exible
bronchoscope, electrocautery can be a powerful tool to ameliorate bleeding. While not essenal, rigid bronchoscopy can be useful to pro-
vide a conduit to beer secure the airway and provide suconing while allowing the applicaon of electrocautery techniques.
Planning:
Planning for the use of electrocautery includes appropriate paent selecon, review of imaging, paent preparaon, and familiarity with
equipment use and sengs.
Appropriate candidates for electrocautery are those paents who would otherwise be able to tolerate bronchoscopy. In addion to cardiac
risk stracaon, the paent must be able to tolerate a fracon of inspired oxygen (FiO2) of less than 40% in order for electrocautery to be
safely applied. The majority of bronchoscopic electrocautery is monopolar in which an electrical current is generated by an acve electrode
contained within the tool and completes the circuit by passing through the paent’s body into the grounding pad. Carefully selecng the
locaon the grounding pad is placed on the paent and possible negave consequences must be considered. The grounding pad should be
placed on a clean, dry and relavely hairless area of skin as close as possible to the lesion of interest within the airway. For example, if the
CAO is occluding the le mainstem bronchus, then the grounding pad should be preferenally placed over the paent’s le chest. However,
careful consideraon must also be paid to the presence of implanted cardiac devices such as pacemakers and implantable cardioverter de-
brillators (ICDs). In the above example, if the paent with a le mainstem obstrucon also had an implantable cardiac device, the ground-
ing pad should not be placed over the le chest as this would draw current through the device and potenally lead it to malfuncon. These
Fundamental Principals and Safety of Bronchoscopic Electrocautery
Atul C. Mehta, MD
Professor of Medicine,
Lerner College of Medicine
Buoncore Family Endowed Chair in
Lung Transplantaon
Sta Physician, Pulmonary Medicine
Cleveland Clinic Foundaon
Grant Senyei, MD, MBA
Intervenonal Pulmonology Fellow
Cleveland Clinic Foundaon
Tips from the Experts
P A G E 8 V O L U M E 1 2 , I S S U E 2
devices must be interrogated before and aer the procedure in the case of pacemakers or disabled pre-procedurally in the case of ICDs to
ensure the funconality during and aer the case.
Bipolar electrocautery devices negate the need for a grounding pad as the acve and return electrodes are in close proximity within the tar-
get site. The path of the electrical current is contained to the ssue between the two electrodes (usually in the form of forceps) rather than
from the tool’s electrode, through the paent’s body, and to the grounding pad as in monopolar electrocautery. However, the ssue eect is
less pronounced than with monopolar devices due to lower power. Bipolar electrocautery is closer to the original form of electrocautery in
which direct current is passed through a metal resistor rather than paent’s ssue to create heat. Both of these techniques are beer suited
for paents who have implantable cardiac devices that cannot be adjusted as the electrical current is less likely to pass through the device.
7
Determining the best airway to be used when employing electrocautery is paent and case-dependent. In general, if the lesion locaon al-
lows, a large-bore endotracheal tube (≥8.5mm inner diameter) or rigid bronchoscope is the airway of choice. If there is high concern for hem-
orrhage, these airways allow for maximal protecon of the contralateral lung and bronchoscopic access to clear the aected lung. Addional-
ly, while electrocautery provides the ability to debulk and coagulate central airway tumors en bloc, this maneuver can create a new challenge
when a previously xed airway obstrucon becomes mobile. Again, the largest conduit to the airway should be considered safest.
Sampling:
Electrocautery can be used for both therapeuc and diagnosc purposes. There are several devices that ulize the cung and coagulave
eects of electrocautery to both therapeucally debulk and obtain ssue for further diagnosis.
Electrocautery snare
An electrocautery snare is a lasso-type tool made of electroconducve material that can be deployed around an airway lesion and cinched
closed. The electrocautery principles of cung and coagulaon are used to excise the lesion while controlling bleeding. The lesion can
then be removed from the airway and sent for addional studies.
Electrocautery knife
An electrocautery knife uses the vaporizaon principles of electrocautery to dissect through ssue. This can be used both as a means of re-
moving scar ssue within the airway and also to create a path through the airway to access mediasnal lymph nodes and facilitate cryo-
biopsy.
Electrocautery forceps
Electrocautery forceps provide the benets of forceps biopsies while also employing the coagulave properes of electrocautery to limit post
-biopsy hemorrhage. There has not been shown to be a detriment in specimen quality between hot and cold forceps.
8
An electrocautery probe is also available to control hemorrhage and ablate ssue. However, many of the indicaons for an electrocautery
probe can be accomplished with the snare or forceps by touching the lesion of concern with the conducng poron of either of these tools.
Regardless of the tool used, there is an insulated and non-insulated poron that allows for electricity to be conducted to the ssue once it is
within the paent. If the non-insulated poron is close to the end of the working channel, the bronchoscope may inadvertently be the lowest
path of resistance for the electric current. Given this high-energy conducon can lead to costly damage to the bronchoscope, it is important
to keep the electrocautery tool at least 4mm from the end of the working channel. Older generaons of bronchoscopes are not amenable to
electrosurgical techniques as they lack an insulated ceramic p, so familiarity with the bronchoscope in use is vital.
Quality control:
The unique, oxygen-rich environment of the intubated paent creates challenges and potenally devastang consequences as it relates to
the use of electrocautery. While this tool can be eecve, the severe ramicaons of an airway re must be the foremost concern of the
bronchoscopist and anesthesia team. In order to prevent this adverse event, connuous communicaon is required. Prior to the procedure,
the potenal use of electrocautery should be discussed. During the procedure, conrmaon of reducon in FiO2 unl an FeO2 ≤40% should
be performed via closed loop communicaon. Finally, if the paent is not tolerang this oxygen level, the bronchoscopist should be made
aware prior to any increase in supplemental oxygen.
Tips from the Experts
P A G E 9 V O L U M E 1 2 , I S S U E 2
References:
1. Li A et al. Gastrointest. Endosc. Clin. N. 2023; 33 (1): 29–40
2. Mazzarweh N et al. Am Coll Sur. 2006; 202 (3): 520-530
3. Lee P et al. Clin Chest Med. 2022; 23 (1): 241–256
4. Mahajan A et al. Chest. 2020; 157 (2): 446-453
5. Ost D et al. Chest. 2015; 147 (5): 1282–1298
6. Coulter T et al. Chest. 2000; 118 (2): 516–521
7. Madigan M et al. Ann Surg. 1999. 230 (5): 639
8. Tremblay A et al. Eur Respir J. 2007; 29 (1): 108–111
Table 1. Key Consideraons When Using Bronchoscopic Electrocautery
Appropriate grounding pad posioning accounts rst for the presence of implanted cardiac devices and
second for the locaon of the airway lesion.
A large endotracheal tube (≥ 8.5) or rigid bronchoscope is the preferred airway of choice for bronchoscopic
electrocautery when the lesion locaon allows.
Use the lowest seng possible to achieve the desired eect while prevenng unnecessary current delivery.
Use closed loop communicaon to ensure the fracon of expired oxygen (FeO2) is ≤40% prior to acvang
the electrocautery tool.
Keep the distal end of the tool at least 4mm from the end of the working channel to prevent damage to the
bronchoscope.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
Arcial Intelligence: Between Wonder and Decepon. An Analysis of Eric
Sadin's Thought
The growth of arcial intelligence (AI) has transformed our lives, enhancing eciency across various sectors. However, sci-
ensts and philosophers have expressed concerns about the associated risks.
A primary concern is the ethics of AI development. As AI systems become more advanced, quesons about moral responsi-
bility and accountability arise. Biases in algorithms, decision-making processes, and their impact on social values provoke
debates among experts.
One ethical dilemma is job displacement due to automaon, which could lead to massive unemployment and economic in-
stability. Policymakers face the challenge of ensuring a smooth labour transion in the AI era. Addionally, privacy implica-
ons are worrisome. The collecon and analysis of vast amounts of data raise serious quesons about data security and indi-
vidual privacy. The misuse of personal informaon by algorithms prompts ethical concerns about consent and data protec-
on.
Beyond ethical concerns, existenal risks related to AI exist. Scenarios where AI surpasses human intelligence and makes
autonomous decisions raise alarms about the potenal consequences of losing control over these systems. Arcial superin-
telligence, which could outperform humans in all cognive tasks, poses profound quesons about humanity's future.
Various contemporary philosophers and theorists address the phenomenon and consequences of AI from dierent perspec-
ves. Nick Bostrom, in "Superintelligence: Paths, Dangers, Strategies," explores potenal future routes of AI and associated
risks. Luciano Floridi, in "The Fourth Revoluon: How the Infosphere is Reshaping Human Reality," examines how infor-
maon technologies and AI reshape our understanding of the world and our role in it. Yuval Noah Harari, in "Sapiens: A Brief
History of Humankind" and "Homo Deus: A Brief History of Tomorrow," explores how emerging technologies, including AI,
could transform society and human nature. Jaron Lanier, with "You Are Not a Gadget" and "Ten Arguments for Deleng Your
Social Media Accounts Right Now," examines the eects of technology on society and the individual. John Searle, with his
famous "Chinese Room" thought experiment, quesons whether a machine can possess true understanding or conscious-
ness. Searle argues that while a computer can produce correct responses by following a program, it does not truly under-
stand what it is doing, suggesng that AI cannot possess genuine understanding or consciousness.
Among these voices, one of the most pivotal contribuons has been by Eric Sadin, a French philosopher and essayist known
for his crical analyses of technology, AI, and social networks. His insights into the intersecon of technology and society,
exploring how technological innovaons aect daily life, power structures, and human relaonships, are parcularly provoc-
ave.
AI represents one of the greatest technological marvels of our me, evoking enthusiasm and awe for its capabilies. This
technology, increasingly integrated into our lives, shapes our values, thought processes, decisions, polical organisaons,
and the knowledge we can obtain through "digital agents." However, Eric Sadin warns that this state of wonder and awe is
also a state of decepon that we must crically queson and analyse. Sadin argues that the fascinaon with AI is actually a
form of decepon perpetuated by its diculty to be recognised. We already live in a digitally shaped era where AI not only
accompanies our decisions and acons but largely determines them.
The ability of expert systems to automacally interpret situaons and generate knowledge inuences how we make deci-
sions and organise ourselves. AI, inially conceived as a tool to support human acons, has evolved into a direct determinant
of these acons and decisions. This evoluon raises a fundamental queson: who produces knowledge today?
Sadin argues that AI has established a new "regime of truth" that asserts unprecedented authority. This algorithmic truth,
produced and validated by digital systems, presents itself as indisputable, thereby liming human judgement. This phenome-
non is concerning because, unlike previous concepons of truth, digital truth does not easily allow for quesoning, imposing
itself as a tyranny.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 11
The digitalisaon of the world has also transformed our percepon of reality. The transhumanist project, which Sadin does
not directly address but is relevant in this context, proposes enhancing the human being through the fusion of biology with
technology, leading to the creaon of a "superintelligence." This perspecve promises a utopia of perfecon and security,
but also implies deep control over human life and its perceptual and emoonal capacies.
One of the most common arguments in defence of technology is its presumed ethical neutrality, meaning that its value de-
pends on how it is used. However, it is clear that digital technology, and AI in parcular, has an "ethical narrowness" rein-
forced by policies promong the control of personal data. Being a cizen in the digital age seems to reduce to being a pos-
sessor of data that must be protected and managed. Current digital ethics focus on data protecon but do not address the
broader implicaons of algorithmic control over human life. Concern for the ethical use of AI should go beyond mere data
protecon and consider how these technologies reshape our interacons, decisions, and values.
The digital revoluon is nearly complete. This powerful technology can explore networks, collect and analyse relevant data,
map myriad global or local situaons, and propose or project real-me secure and opmal soluons. Many systems are al-
ready capable of making decisions on our behalf, contribung to an insidious and expansive delegaon of power to ma-
chines. This phenomenon marginalises humanity, whose intellectual aributes are partly surpassed by its own creaons.
In his book L'humanité augmentée. L'administraon numérique du monde, Éric Sadin explores numerous phenomena al-
ready in full operaon and poised to expand considerably in the coming years. He notes the unseling emergence of a kind
of parallel humanity, composed of intelligent electronic ows designed to manage "for the best and least risk" the course of
the world in the 21st century. The ideal of augmented humanity is based on the noon that God made a mistake with us: He
made us incomplete, unnished, insucient. Technology—more precisely, the technical-economic proposal of our me—
has miraculously come to solve all our problems, says Sadin. This civilisaonal ideal, now established as a desirable scheme
for our existence, stems from the subtle and constant exercise carried out for years by mass media, mulnaonal corpora-
ons, and governments worldwide.
In this context, the "siliconisaon of the world" takes on the vigour of a universal social scheme that organises personal and
professional life in the "civilised" world. This model, explains Sadin, is based primarily on an "automated algorithmic organi-
saon," dened by the quancaon of human beings, now reduced to mere data housed in massive electronic databases
owned by private companies and organisaons. This form of organisaon allows all social life to be governed by digital ad-
ministraon.
Secondly, the civilisaonal model based on the siliconisaon of the world is observed in another globally accepted phenome-
non: the commodicaon of life. Our data, interacons, and ways of life, constantly traversed and ltered through technical
surfaces and plaorms, are now valued almost exclusively for their commercial value. Even we, our images and representa-
ons, are presented as objects or products with commercial character.
The siliconisaon of the world, Sadin explains, is celebrated as not only a desirable but also an unsurpassable model: a lumi-
nous form of the most exacerbated technocapitalism, welcomed with reworks for its "egalitarian virtues" and promises of
"freedom of access."
This siliconisaon operates through missionaries who have arrived to colonise the planet with ideas radiated from the very
heart of Silicon Valley: the "startuppers," the "creave collaborators," the "autonomous self-entrepreneurs," the "think
tanks," the project incubators, even the universies, all of them now mulplied across all connents as the new evangelisers
of the future.
Here is something central, remarks Sadin: without realising it, the "enabling technologies," the surfaces and technical devic-
es that make up the "data and plaorm economy," are leading us to a way of life that has no polical end but is mercanlist
and global, intended solely to sasfy private interests. The problem with the bright projects that come to us as discourses of
light and salvaon from the media and from the voices of their missionaries and evangelisers is that we are carrying out and
allowing the realisaon of the most extreme version of posivism: a "radical anhumanism" that aacks individual freedom
of decision and judgement.
As an example, Sadin discusses the inuence of social networks, parcularly Twier. Twier, a social network used by hun-
dreds of millions of ordinary people as well as celebries and polical leaders, also feeds on a parcular form of expression
that has lile to do with a global agora. The approach to this and other plaorms must be inserted into the analysis of the
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
new condion of the contemporary subject, which, although it materialised in the last decade, goes back more than two
centuries and has individualism as its predominant ethos. When Twier's creator proposed that users post messages inially
limited to 140 characters, he probably understood that the rule of short formulas would smulate a dynamic of exchanges
capable of creang a sort of global chorus where humans could express themselves simply and almost spontaneously.
What immediately made the device unique was that it seemed to resonate, disturbingly, with an increasingly restless era
subjected to unprecedented threats. The plaorm responded to the needs of the me, stoking human resentment and an-
ger. The enre mechanism fosters the impression of a primacy of oneself that is maintained all the more because each post
seems to come from nowhere, emerging ex nihilo—in contrast to societal exchange that always derives from response, from
the intertwining with other words—thus feeding the implicit postulate of embodying a form of truth.
Eric Sadin argues in his book La Vie algorithmique: Crique de la raison numérique that Twier was used to share moods,
frustraons, and dissasfacons about various situaons and instuons, making us feel like protagonists of our lives. It
seemed like a new right to unlimited expression, almost like a public service. Later, the "like" was introduced, providing sec-
ondary sasfacon. The sophiscaon of the device oered gracaon to both the "followed" and the followers, creang
an illusion of proximity with celebries. Users, by menoning or "tagging" personalies, imagined a direct interacon,
though they rarely received responses. This illusion fed the feeling of being involved in world aairs. Not only ordinary peo-
ple but also celebries were electried, using it to maintain their presge without intermediaries.
This intoxicang machine is also supported by the interface that forces concise posngs, favouring a language regime that
priorises asseron over argumentaon on the central issue. According to Sadin, this constutes coercion that further ex-
cites the desire to systemacally produce impacul, whip-like phrases, punchlines intended both to impact other minds and
to disnguish oneself from the average. This marks "the era of haste," without reecon, without exchange, without waing
for a response, but merely accounng for likes and retweets. The "conversaon" ended, giving way to catharsis.
According to Sadin, the plaorm collaborated with the absolute privilege assigned to the word. We are living in a moment of
inaon of discourses, whether formulated on the web, in radio studios, or on television channels broadcasng 24 hours a
day, which since the early 2000s have mulplied debates in formats designed to smulate turbulent exchanges.
A dislocaon occurs then—on a scale probably never before seen in history—between word and con. The passion for ex-
pressiveness now occupies a predominant posion and also has the eect of relegang to the background any duty of real
involvement in common aairs. Sadin quotes Hannah Arendt: "Of all the acvies necessary and present in human commu-
nies, only two were considered polical and capable of constung what Aristotle called bios polikos, that is, acon and
speech." In this equaon, praxis is rst chronologically—and also morally—and only later calls for commentary, the individu-
al and collecve evaluaon of the achievements realised, intended to feed and iniate acon anew. This was a signicant
contribuon to an-polics: nothing is done, nothing proposed, nothing built. Opinions are expressed, generally violently,
and that is the enrety of the individual's involvement: "I have an opinion." But nothing is done to change what is cricised
or improve what is considered a problem.
More than the duty of polical contribuon theorecally conferred to all, which requires public pronouncement and eort
to contribute to the life of the City, a generalised good conscience now prevails. The constant pracce of expressing well-
intenoned words amid protests gives "users" the impression of moral integrity and being "on the right side." Thus, the re-
less pracce of declamaon gives the sensaon of being "on the right side" while remaining, for the most part, outside real
acon. Living on the margins, never being a protagonist, but living under the illusion of being a main character because one
is followed and follows a series of asserve comments not exposed to transformave dialeccs.
It is then when we realise that we are not dealing with an enty dedicated to establishing connecons but with a constantly
bubbling mechanism that aracts a multude of human monads, aspiring only to soothe their emoons and capture others'
aenon. Contrary to what we imagine, this dynamic dismantles each of us as acng beings.
But perhaps one of the most provocave and alarming points analysed by Sadin is the progressive transformaon of Arcial
Intelligence from being a prosthesis to an anthropomorphic enty.
Eric Sadin, in his provocave and challenging style, argues that "Francis Fukuyama was mistaken: the end of history did not
arrive with the fall of the Berlin Wall in 1989 and the global triumph of polical and economic liberalism, but rather is being
consummated today with the widespread use of arcial intelligence."
Humanitarian News
W A B I P N E W S L E T T E R P A G E 13
The central hypothesis of L'Intelligence arcielle ou l'Enjeu du siècle: Anatomie d’un anhumanisme radical is that the pre-
dominance of arcial intelligence (AI) is not a consequence but a cause, derived from a fundamental change in the status of
digital technologies. These technologies have evolved from being accumulave and intellectual prostheses, useful for the
storage, indexing, and rapid trac of informaon, to becoming enes expected to enunciate truths through the automated
interpretaon of situaons. Inially seen as tools that augment our cognive abilies, they now assume a much more acve
role. They no longer merely store and organize informaon but are aributed the capacity to interpret data and generate
knowledge beyond human capability.
This ability of AI to arculate truths that humans cannot discern fundamentally alters the nature of technology. The implica-
ons of this change are vast and profound. We nd ourselves at a crossroads where digital technology not only supports our
decisions but largely determines them.
What characterizes arcial intelligence is its power of experience, which constantly improves. We are witnessing a shi in
the status of digital technologies, which are no longer merely intended to enable us to manipulate informaon for various
purposes but to reveal the reality of phenomena beyond appearances. AI can establish more precise diagnoses than human
intelligence because it handles and correlates data in real-me, which esh-and-blood humans cannot match. In this sense,
the French philosopher denounces "the propagaon of a radical anhumanism," as techno-liberalism, through a managerial
neo-language, seeks to "reduce certain elements of reality to binary codes, excluding an innity of dimensions that our sensi-
vity can capture and that escape the principle of mathemacal modeling."
This can vary from a moderate and harmless level to a prescripve one, such as in the recruitment sector, which now uses
digital systems to select candidates for a job. "We are witnessing the marginalizaon of human evaluaon."
In his earlier works, such as La humanité augmentée : L'administraon numérique du monde and La silicolonisaon du
monde, Sadin gained ground among 21st-century dystopian thinkers, arculang in real-me, from a phenomenological per-
specve, what millions of television viewers perceived as a warning in the series Black Mirror: the advent of radical changes
in the construcon of "the real." These modicaons, the philosopher notes, are subsidiaries of transformaons evident in
the status of digital technologies, which have shied from being "accumulave prostheses" to becoming enes capable of
"enunciang truth" through automated interpretaon of situaons. Technology thus becomes "anthropomorphic," realizing
in the 21st century what Simone Weil foresaw in La condion ouvrière: "things play the role of humans, and humans play the
role of things; it is the root of evil."
Thus, the singularity of beings and human plurality are gradually neutralized through automated modes of organizaon that
avoid conict, deliberaon, and consensus. As we connuously strive to govern ourselves, these systems establish a strictly
ulitarian relaonship with existence, assuming that every acon must aim towards an end, whether it is supposed comfort
or the opmizaon of life sequences.
The digital medium provides a more dependable way to evaluate "reality" compared to our current methods. This is appar-
ent in the eld of nancial management, online social plaorms, GPS technology, and even in the legal system through court
decisions and video monitoring. Currently, a unique and never-before-seen anthropological and ontological condion is
emerging. In this condion, the human form is subjected to the calculaons of its own creaons, with the main objecve of
serving personal interests and creang a societal structure primarily driven by praccal consideraons.
This revoluon has revitalised the concept of "ideology of progress," resulng in the establishment of an idealised govern-
ment. It is important to recognise that artefacts are not a result of any inherent natural order, but rather they are created by
human intervenon and have an impact on human acvies. According to Sadin, AI is not fundamentally dierent; it has not
naturally evolved to become a replacement for our decision-making abilies. Instead, it serves as a tool for maximising e-
ciency in decision-making, which has diminished the amount of me humans spend on understanding and reecon.
This myth of technological neutrality, Sadin tells us, also manifests in the messianic image of "visionary entrepreneurs" who
spearheaded modern compung. Figures like Steve Jobs, Bill Gates, Mark Zuckerberg, and Elon Musk are presented to the
public through their autobiographies as enlightened beings, touched by the "invisible hand" of inspiraon, portraying their
products as fruits of their individual creave fervour and cloaking them in a "virginal innocence," far from any responsibility
for the misuse of their products. Yet, it would be naive to believe that the rise of the PC was due to the iniave of a young
Humanitarian News
W A B I P N E W S L E T T E R P A G E 14
man in his parents' garage, soldering iron in one hand and a circuit board in the other. The ocial narrave conceals the
economic interests that dictated the trajectory of research in this sector.
Technology (like science) is anything but neutral. AI does not "know" innately; it knows what it is fed. And those who pro-
duce the mega AI systems are private companies responding to their own interests, not a supposed "truth" or the general
interest. What will Chat-GBT tell us about the interpretaon of a parcular geopolical problem? What will a medical AI so-
ware tell us about the criteria for dening a disease: the strictest that includes fewer paents (and hence fewer treatment
targets) or the most exible that signicantly increases potenal subjects for treatment? How will AI interpret an academic
text when it "digests" it for us to read more quickly? And progressively: what will it tell us (depending on who has fed it)
about what is true and what is not, about what is right and what is wrong?
One of the major problems is that we trust technology more than ourselves. A prime example is the beauful Sophia project
to improve diagnosc accuracy in tomographic paerns of intersal disease. An undoubtedly useful tool. However, it is
signicant that in the preliminary analysis of the work by Simon Walsh, when parcipants (all of them expert radiologists or
pulmonologists in intersal disease) analyzed nearly 300 HRCTs and then received the AI's opinion, most of them changed
their inial assessment to a greater or lesser extent. The condence in the AI system (with or without reason) was greater
than the condence they had in themselves.
According to Sadin, from now on, we increasingly expect processors to govern us masterfully, to liberate us from having to
pronounce ourselves at every moment and to generate commitment; in essence, the act of pung our responsibility at
stake. He connues: "What is at stake is the denial of our vulnerability, that constuve fragility of our humanity that led
Aristotle to say, 'a life so vulnerable is nevertheless the best.'"
In this new regime of truth, the philosopher argues, postmodern categories imposed in the late 20th century are no longer
useful. "It is not so much about 'control' and the abusive collecon of 'personal data' but about a quite dierent congura-
on whose goal is not to monitor but to inuence behaviours," he writes. This "algorithmic Leviathan" cannot be confronted
like the old instuonal power devices, since "we can never have it in front of us, so that, with total clarity, we can know
what it is about, because it never shows us its enre face and indenitely escapes, free thus to exercise its full powers, shel-
tered from any form of consistent opposion."
In the era of the tyrannical individual, the lack of faith and the inuence of social networks have led to a society without a
common horizon, where resentment and distrust prevail. The proposed soluon is to rebuild collecves that allow people to
express their capacies harmoniously and sustainably. Our history is marked by promises and disappointments, both individ-
ually and collecvely, leading to a parcular state of successive disillusionment.
In this context, it is crucial to reect on the ethical, social, and philosophical implicaons of this transformaon. We must
queson the uncrical enthusiasm towards AI and carefully consider how we want these technologies to inuence our lives
and sociees. The capacity of AI to generate truth and make autonomous decisions can be a powerful tool, but it also poses
signicant risks that we must address with crical awareness and strong ethics.
Humans are diverse individuals, characterised by their wide range of dierences and inherent mulplicity. We are social be-
ings who exist in a state of conict and disagreement. We exist as complex enes with the ability to perceive and experi-
ence the world through mulple senses, while also being part of a diverse and intricate society. Embracing the concept of
global siliconizaon, exponenal technologies, and convergence entails the complete eradicaon of human qualies, ul-
mately resulng in the demise of polics.
It is crucial for us to have a keen understanding of the power and inuence that techno-liberalism is currently exercising over
our lives. In order to secure the future of our human civilizaon, it is imperave that we promptly iniate measures to coun-
teract opposing forces, establish limits, or resist them. The civic and polical mobilisaon we engage in during the next 10 to
15 years will play a signicant role in determining the outcome. According to Sadin, once that happens, it will be too late.
Sadin lacks opmism. Nevertheless, notwithstanding his disillusionment, he revisits Foucault in order to urge the populace to
exhibit "acve intolerance" in opposion to the radical dehumanisaon generated by techno-liberalism. "Defending the real
becomes the new singular name of the most signicant polical struggle of our me," he concludes, evidently lacking the
enthusiasm that would movate readers.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 15
References:
1. Sadin É.. La humanité augmentée : L'administraon numérique du monde. Paris : L’Échappée, 2013.
2. Sadin, É. La silicolonisaon du monde : L’irrésisble expansion du libéralisme numérique. Paris : L’Échappée, 2016.
3. Sadin É. L'intelligence arcielle ou l'enjeu du siècle : Anatomie d'un anhumanisme radical. Paris : L’Échappée, 2018."
4. Sadin É. La Vie algorithmique : Crique de la raison numérique. Paris : L’Échappée, 2015.
5. Sadin É. L’Ère de l’individu tyran : La n d’un monde commun. Paris : Grasset, 2020."
6. Sadin Éric, « « Le technolibéralisme nous conduit à un “avenir régressif” » », Hermès, La Revue, 2018/1 (n° 80), p. 255-258. DOI :
10.3917/herm.080.0255
*The views expressed in this arcle are those of the author (Silvia Quadrelli) and do not necessarily reect the ocial posi-
ons of the Execuve Board or Internaonal Board of Regents of the WABIP.
Best Image Contest 2024 (2 of 3)
Category: Central Airway Diseases
Descripon: Videobronchoscopic tracheal view of a right main bronchus ovarian cancer me-
tastasis with carinal and le main brocnhus envolvment. The tumor was debulked with elec-
tocautery and extracted with the help of cryoprobe.
Submier(s): Gutu Serghei
Best Image Contest
P A G E 16
This image is 1 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 17
WABIP News
Upcoming Deadlines and Opportunies
We are excited to announce several important iniaves and opportunies for our members in the upcoming
months. These events and nominaons are crucial for recognizing outstanding contribuons in the eld of bron-
chology and intervenonal pulmonology, as well as for fostering further advancements and collaboraons within
our community.
WABIP Awards
Nominaons for the presgious WABIP Awards are now open, with the deadline set for July 1, 2024. The awards
will be presented during the opening ceremony of the WCBIP Congress in Bali, Indonesia. We encourage members
to submit nominaons for the following awards:
• The Gustav Killian Centenary MedalRecognizes accomplished senior bronchologists with signicant career
achievements.
• The WABIP-Dumon Award: Honors individuals dedicated to enhancing technical skills and knowledge in rigid
bronchoscopy.
• The Heinrich Becker Young Invesgator Awards: Celebrates young researchers and clinicians contribung to
bronchology-related paent care and innovaons.
• The WABIP Lifeme Achievement Award: Acknowledges rered professionals who made considerable contri-
buons to bronchology and intervenonal pulmonology.
• The Disnguished WABIP Regent Award: Recognizes signicant contribuons by members of the Board of Re-
gents.
WABIP Awards: READ MORE
WABIP Vice-chair Nominaons
We are now accepng nominaons for the next WABIP Vice-chair, with a submission deadline of July 1, 2024. The
elecon will take place during the WABIP Board of Regents meeng at the WCBIP Congress on October 23, 2024, in
Bali. The elected Vice-chair will join the Execuve Board and assume leadership responsibilies to ensure the con-
nued growth and success of our organizaon. READ MORE
WCBIP 2028 Bids
Applicaons to host the 2028 WCBIP Congress are open! This is a unique opportunity to bring our biennial scienc
event to your city and showcase your venue. Applicaons must be submied by July 1, 2024, and selected appli-
cants will present their proposals at the Board of Regents meeng in Bali. We look forward to seeing your innova-
ve ideas and plans for hosng this signicant event. READ MORE
WCBIP Video Fesval
We invites submissions for the WCBIP Video Fesval. We seek videos showcasing “state of the art” updates and
procedural techniques in intervenonal pulmonology, laryngology, pleural diseases, tracheobronchology, and
esophagology. An independent jury will judge submissions, awarding prizes in categories such as Scienc Content,
Innovaon, and Imaging. The best overall video will be presented at the Congress's Opening Ceremony and will be
featured on WABIP's social media plaorms. The submission deadline is July 1, 2024. READ MORE
We encourage all members to parcipate in these excing opportunies and to help us recognize and celebrate
the exceponal work within our community. Your contribuons and involvement are vital to the success and ad-
vancement of our eld.
When a PET scan is just not enough!
Mediasnal staging is the cornerstone of lung cancer staging, especially in the absence of proven distant metastases.
Previous studies have shown that CT/radiographic criteria for mediasnal and hilar adenopathy excludes a substanal number of paents as con-
rmed by Endo Bronchial Ultrasound-Guided Transbronchial Needle Aspiraon (EBUS TBNA). By the same token, the most accurate and reliable
method of staging/metastac disease, the PET scan, is not precise enough anymore either. Past studies showed that up to 7-8% of the paents
with PET- negave mediasnal and hilar adenopathy were found to have tumors.
New data now suggests that the impact of under or over-staging in a lung cancer diagnosis has signicant consequences in paents, as their care
plans are developed, involving surgical and non-surgical treatments for lung cancer, leading to poor outcomes.
The SEISMIC (1) study focuses on a large group of lung cancer paents, accounng for about one-third of all lung cancer paents with locally ad-
vanced adenocarcinoma requiring treatment based on their T3 -T4 and N2-N3 status. The implicaon is stage IIIA or IIIB disease, which aects the
decision of pursuing resecon and determining the potenal eld of radiaon. The treatment plan determined by the more accurate staging deter-
minaons leads to more favorable disease-free survival outcomes.
In the SEISMIC study 155 paents from seven dierent countries were studied in a single arm, prospecve study. These paents were suspected of
locally advanced disease, requiring invasive staging with EBUS TBNA aer a PET scan and before any chemotherapeuc or radiaon intervenon
could be administered. The primary endpoint of the study showed the signicant percentage of PET-negave paents/nodes that upon more accu-
rate staging with EBUS TBNA were found to be metastac. The study found that 37% of the paents had discrepancy in their PET and EBUS TBNA
results. Of the 37%, 12% had an EBUS TBNA posive result for metastasis while PET scans showed a negave result. Contralateral-N3 metastasis
was found in 7% of these paents with PET-negave scans leading to upstaging of cancer. EBUS TBNA results led to a clinically signicant change in
their treatment plan. Hence, these paents would have undergone treatments plans including radiaon therapy or surgical intervenon inaccurate
to their staging if based solely on the PET scan results, without the staging assessment of bronchoscopic EBUS TBNA.
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief WABIP
Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 18
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
Ali I. Musani MD, FCCP
Professor of Medicine and Surgery,
University of Colorado School of
Medicine, Denver
The standard guidelines recommend a PET scan as a metastac workup for locally invasive and unresectable adenocarcinoma of lung cancer,
however the growing evidence of PET-negave but EBUS TBNA-posive mediasnal and hilar nodes suggests that the me has come to re-
visit the guidelines and consider the necessity of ssue sampling for accurate staging of locally advanced and unresectable lung cancer and
appropriate treatment. The study also showed that EBUS TBNA idened less extensive involvement of mediasnal and hilar nodes than PET
in 25% of the paents. 20% of these paents were downs staged from N3 and N2 to N2 or N1 disease leading to tumor resecon. The post -
operave ssue analysis conrmed EBUS TBNA ndings in all paents.
The implicaons of ssue sampling/invasive staging of the mediasnal and hilar nodes are substanal in more accurate staging assessments
of locally invasive adenocarcinoma. Many large academic centers have already adopted the approach of ssue sampling regardless of PET
posivity, but naonal and internaonal standard of care guidelines have not adopted this necessary change.
A well-trained intervenonal pulmonologist, who is well versed in proper and systemac staging from N3 to N2 to N1 lymph nodes and ob-
taining samples from every lymph node above 6-7 mm in size, oers the best hope for proper staging and treatment of lung cancer. Merely,
“scking a needle in a couple of large mediasnal lymph nodes” is not accurate or reliable lung cancer staging. CT criteria of 1 cm or even
8mm for adenopathy is not acceptable anymore. A systemac approach with a lung cancer staging algorithm, regardless of PET avidity,
should be performed when there is a mediasnal or hilar adenopathy based on ultrasound criteria.
Reference:
1. Steinfort D et al: Lancet Respir Med . 2024 Jun;12(6):467-475.
Research
P A G E 19
P A G E
20
WABIP ACADEMY- WEBCASTS
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
W A B I P N E W S L E T T E R
Links
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
surgeons.
www.jrs.or.jp The Japanese Respirology Society
sites.google.com/site/asendoscopiarespiratoria/
Asociación Sudamericana de Endoscopía Respiratoria
P A G E 20
