Volume 13
Issue 01
January 2025
Inside This Issue
Editorial, 2-3
Technology Corner, 4-6
Tips from the Experts, 7-9
Humanitarian News, 10-14
Best Image Contest, 15
WABIP News, 16-17
Research, 18-19
Links, 20
The 2023 American Association for Thoracic Surgery Expert Consensus
Document on the Management of Subsolid Lung Nodules provides
answers…and more questions
WABIP Newsletter
J A N U A R 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
Committee Chair
Aleš Rozman, MD, PhD
Slovenia, Education Com-
mittee Chair
Danai Khemasuwan, MD
USA, Finance Committee
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
Newsletter Editor-in-chief
P A G E 2
An increase in the utilization of Chest CT imaging,
both for lung cancer screening and other indications,
has identified an increasing number of subsolid lung
nodules. Although the majority of these nodules
represent benign disease, a significant number are
found to be malignancies; specifically, lesions in the
early spectrum of lung adenocarcinoma. Biologically,
these radiographically subsolid lung cancers tend to
exhibit more indolent behavior and patient out-
comes are better as compared to radiographically
solid lung cancers. However, these lesions can also
represent invasive pathologies that have the poten-
tial to metastasize. As a result, the management of
subsolid lung adenocarcinomas requires a
thoughul balance of early intervention for curable
lesions while avoiding overtreatment of lesions that
may never impact an individual’s survival. The re-
cently published 2023 American Association for Tho-
racic Surgery expert consensus document (ECD) on
the management of subsolid nodules
1
aims to pro-
vide clinicians with guidelines to help with this nu-
anced decision-making, but also makes clear that
many questions still remain.
The ECD begins with a definition of terminology,
which may be one of the most important messages
of the entire document. Subsolid refers to a CT-
identified focal ground-glass opacity (GGO) with vari-
able solid components within which the presence of
underlying pulmonary vessels or bronchial struc-
tures remain visible, serving as an umbrella term for
any lung nodule that is not considered solid. The
subsolid category is then broken down into two sub-
categories: non-solid (also known as pure GGO) and
part-solid.
1
There is significant heterogeneity in how subsol-
id lung nodules are described in the literature, with some
broadly using the term “GGO” to refer to any subsolid lung
nodule as well as those who describe subsolid lesions based
on the consolidation/tumor ratio (CTR). For future research,
it will be important to encourage greater uniformity in the
language used to describe subsolid lung nodules for better
communication and more efficient scientific progress.
Another important topic that was addressed in the ECD is
the duration of surveillance for subsolid lung nodules. Stud-
ies have shown that subsolid lung nodules may remain sta-
ble for many years prior to growing in size or density. For
example, Lee et al performed long-term follow up of pa-
tients that had subsolid lung nodules that were already
demonstrated to be stable over the course of five years.
After an additional five years of surveillance (more than 10
years in total), 13% of nodules progressed.
2
As a result, the
ECD recommends that subsolid lesions that are stable for
five years are followed for at least ten years. This does po-
tentially create a long-term burden for patients, clinicians,
and health systems as a whole, and increases the demand
for multi-disciplinary lung nodule programs to streamline
care and optimize follow-up while providing expert recom-
mendations.
3,4
In addition, future research to discover
methods of predicting lung nodule behavior over time will
be critical.
The ECD also provides recommendations for the specific
staging of non-solid/pure ground glass lung nodules, a topic
of immediate practical importance. Studies suggest that
PET/CT and Brain MRI are unlikely to play a role in the pre-
operative work-up of pure GGOs, which have an essentially
non-existent risk for metastasis.
5,6
By extension, invasive
Jane Yanagawa, MD
Associate Professor of Thoracic Surgery ,
University of California, Los Angeles (UCLA)
W A B I P N E W S L E T T E R
P A G E 3
References:
1. Chen H et al. J Thorac Cardiovasc Surg 2024;168:631-47
2. Lee HW et al. J Thorac Oncol 2019;14(8):1370-1377
3. Verdial FC et al. Chest 2020 Apr;157(4):985-993
4. Roberts TJ et al. Oncologist 2020 May;25(5):431-437
5. Zhuge L et al. J Cancer Res Clin Oncol 2019;145(2):503-509
6. Cho H et al. J Thorac Cardiovasc Surg 2015;150(3):514-520
7. Saji H et al. Lancet 2022;399(10355):1607-1617
8. Altorki N et al. N Engl J Med 2023;388(6):489-498
9. Suzuki K et al. J Thorac Cardiovasc Surg 2022;163(1):289-301
10. Zhang C et al. J Thorac Cardiovasc Surg 2024 Mar;167(3):797-
809
mediastinal staging with EBUS or mediastinoscopy
is not required in this clinical scenario. Because
part-solid lung nodules likely have an invasive com-
ponent, the ECD recommends usual staging prac-
tices for these lesions. Whether current recom-
mendations for lymph node dissection in quality
lung cancer surgery apply to these non-solid, pure
ground glass lesions will also be an important area
of study in the future.
Based on the recent JCOG0802
7
and CALGB140503
8
trials, the ECD also recommends sublobar resec-
tion, when possible, for subsolid lesions that are
peripheral and less than 2 cm. Lobectomy may still
be reasonable for lesions that are central or great-
er than 2 cm, particularly when adequate margins
cannot be achieved with a lesser resection. Unlike
solid lesions where the aggressive biology of the
disease likely carries the greatest weight in deter-
mining survival, we may find one day that the ex-
tent of local therapy actually matters the most for
subsolid lesions. Focus has now turned to the ques-
tion of when to perform a wedge versus seg-
mentectomy for these lesions. In the prospective
single-arm study of sublobar resection for periph-
eral subsolid lesions with a CTR <0.25, where the
majority of patients (82%) underwent wedge resec-
tion, the investigators demonstrated an impressive
5 year relapse-free survival of 99.7%.
9
However, in
a large retrospective study of wedge resections
versus segmentectomy for subsolid lung nodules,
Zhang et al. found that subsolid lesions with a CTR
>0.5 (regardless of size) and subsolid lesions be-
tween 2-3 cm (regardless of CTR) had worse out-
comes with wedge resection.
10
The controversy of
wedge versus segmentectomy is just starting to be
addressed.
In summary, the management of radiographic sub-
solid lung adenocarcinomas is not clear-cut. Due to
the indolent nature of the disease and improved
outcomes, our decisions carry significant weight for
the well-being and quality life of our patients. The
ECD aims to provide a basic framework for the ap-
proach to the majority of patients with subsolid
lung nodules, but does not address all clinical sce-
narios. Additional clinical and translational re-
search is needed to improve our understanding of
the biology of early spectrum lung adenocarcinoma
and ultimately allow more precise surveillance,
diagnostic, staging, and therapeutic recommenda-
tions in the future.
W A B I P N E W S L E T T E R
P A G E 4
Technology Corner
Pafolacianine for Intraoperative Molecular Imaging (IMI) of lung cancer
Introduction
The goal of the surgical oncologist is to accurately differentiate malignant tissue from benign tissue and to remove the entire cancer
while minimizing the removal of non-cancerous tissue. Thoracic surgeons face unique challenges during pulmonary resections, in-
cluding (1) identification of small primary, synchronous, or metachronous pulmonary lesions; (2) accurate identification of lymph
nodes with cancer cells; (3) assessment of margins and differentiation of tumor from surrounding critical structures; and (4) recogni-
tion of residual disease following tumor resections. Until recently, thoracic surgeons have only had two intraoperative tools, visual
inspection and manual palpation, to meet these challenges. Intraoperative molecular imaging (IMI), the use of a fluorescent dye that
selectively accumulates in tumors and an imaging system to highlight the dye in the tumors, is an emerging technology to add to the
arsenal of intraoperative tools. Pafolacianine, the only FDA-approved targeted near-infrared (NIR) contrast agent for lung resections,
can improve identification of small lung nodules and has been shown to improve oncologic operations.
Background
MI utilizes a targeted fluorescent molecule that is injected into the patient, localizes to the tumor, and then a wavelength-specific
camera system is used to detect the fluorescence in the cancer. Fluorescent dyes emit light in a range of wavelengths, from ultravio-
let (UV) to infrared. Dyes with emission in the NIR range (700-1000nm) have decreased autofluorescence and increased depth of
penetration compared to dyes in the visible light spectrum and an improved safety profile over UV dyes. IMI can identify as few as
10
4
cancer cells and can locate nodules as small as 0.5mm in laboratory conditions.
Dyes with tumor-specific accumulation allow identification without a priori knowledge of the presence or location of the can-
cer. Pafolacianine, a folate analogue conjugated to the NIR dye S0456, is a fluorescent imaging agent that binds folate receptor (FR)
with approximately 1nM affinity. Folate receptor (FR) is overexpressed on 85% of lung malignancies. The dye can be administered 2
to 12 hours prior to surgery, and the Stryker 1788, a commercially available thoracoscope, can detect the tracer. Clinical trials have
shown safety and minimal toxicity.
Kelly A. McGovern, MD
Thoracic Surgery,
Hospital of the
University of
Pennsylvania,
Philadelphia, PA
Sunil Singhal,MD
Thoracic Surgery,
Hospital of the
University of
Pennsylvania,
Philadelphia, PA
Katherine O. Welch, MD
Thoracic Surgery,
Hospital of the
University of
Pennsylvania,
Philadelphia, PA
W A B I P N E W S L E T T E R
P A G E 5
Clinical Application
Surgery for pulmonary malignancies is challenging in several ways, including detection of synchronous or metachronous disease, lo-
calization of small nodules, and margin assessment. These challenges have become even more relevant with the increased use of
video assisted and robotic assisted thoracoscopic surgery, now used in approximately 40% of cases, further limiting surgeons’ ability
to perform manual manipulation. In a multi-institutional Phase II study, IMI with pafolacianine improved outcomes for 26% of pa-
tients undergoing pulmonary resection for NSCLC, either by identifying synchronous lesions, localizing nodules, or assessing margins,
demonstrating that IMI is a useful adjunct for pulmonary resections.
In the multi-institutional, randomized Phase III ELUCIDATE Trial, 53 of 100 patients who were randomized to IMI with pafolacianine
(53%) experienced at least 1 clinically significant event, namely identification of synchronous lesions, localization of primary nodules,
and/or margin assessment. The most frequent clinically significant event was the identification of a close margin. Identification of an
otherwise undetectable primary nodule occurred in 19% of participants.
If a synchronous lesion is missed during surgery, it may be difficult to identify on surveillance scans due to postoperative scars, effu-
sions, and atelectasis. Identification of synchronous or metachronous lesions may upstage the patient, and in some cases may change
the need for adjuvant therapy. Improved intraoperative identification of these synchronous lesions by IMI provides an opportunity
for improving long-term survival.
Localization of small nodules may be challenging intraoperatively with inspection and palpation alone, especially with ground glass
opacities which often lack visible structural changes. IMI increases surgeon confidence in localization of primary nodules, thereby
avoiding unnecessarily increasing in the scope of the operation.
Rapid back-table margin assessment with IMI typically takes less than 2 minutes, while frozen section requires approximately 25
minutes. Positive surgical margins have enormous oncologic implications, including increased risk of mortality. The immediate feed-
back provided by IMI in the clinical trials increased surgeon confidence when close margins were a concern, particularly in the case of
ground-glass opacities which often display subtle or no changes.
Discussion
IMI is a new tool for the surgeon in thoracic surgical oncology. Multiple clinical trials have shown IMI with pafolacianine improves
outcomes for patients undergoing pulmonary resection for NSCLC, thus this agent is a useful adjunct for pulmonary resections.
A targeted NIR contrast agent, pafolacianine, improves identification of small lung nodules compared to other fluorescent dyes by
specifically targeting pulmonary adenocarcinomas and other FR-expressing tumors. Pafolacianine is particularly helpful in identifying
sub-centimeter primary, synchronous, or metachronous pulmonary lesions, which are not typically identified on preoperative FDG-
PET. A significant number of patients have their disease upstaged with the addition of IMI with pafolacianine. Without IMI, these pa-
tients would not receive appropriate adjuvant treatment due to failure to identify synchronous disease.
One of the major limitations of IMI is depth of penetration. Dyes that fluoresce in the visible spectrum only penetrate through a few
millimeters of tissue, while NIR dyes have a 1–2 cm maximum depth of penetration. Advances in fluorescent probes and cameras
targeting the short-wave infrared imaging (950-1400nm) may improve the depth of penetration in IMI in the future. There is de-
creased tissue scatter and auto-fluorescence at these wavelengths, which improves detection of smaller, deeper tumors in animal
models.
W A B I P N E W S L E T T E R
P A G E 6
In conclusion, IMI with pafolacianine for thoracic malignancies significantly improved oncologic outcomes. More phase III trials are
needed to determine IMI impact on patient outcomes and overall clinical value. Future research will involve the development of
drugs targeted to other receptors that are upregulated in thoracic malignancies. As more fluorescent dyes are developed, the use of
a cocktail of imaging agents may provide a rapid intraoperative diagnosis, decrease the total operative time, decrease the rate of con-
version to open procedures, and facilitate a more complete oncologic surgery. IMI is applicable to all solid tumors and will be increas-
ingly utilized as new tumor-specific fluorescent contrast agents are developed and the sensitivity and accessibility of commercially
available imaging systems continues to improve.
Figure: Pafolacianine identifies pulmonary malignancies with intraoperative imaging techniques, providing real-time feedback for the thoracic onco-
logic surgeon, as shown by the representative case.
References:
1. Okusanya OT et al. Eur J Cardiothorac Surg. 2018 Mar; 53(3):512–518.
2. Holt D et al. PLoS One. 2014 Jul 29;9(7):e103342.
3. Gangadharan S et al. Multiinstitutional Ann Thorac Surg. 2021 Oct;112(4):1150-1159
4. Predina JD et al. Ann Thorac Surg. 2018 Mar;105(3):901-908.
5. Sarkaria IS et al. J Thorac Cardiovasc Surg. 2023 Dec;166(6):e468-e478.
Tips from the Experts
P A G E 7 V O L U M E 1 3 , I S S U E 1
Introduction
Due to application of broader screening guidelines, increased bronchoscopic biopsy accuracy, and increased application of endobronchial
ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), we should expect an increase in earlier stage non-small cell lung cancer
(NSCLC) diagnoses. While video-assisted thoracoscopic surgery (VATS) is the preferred surgical approach for pulmonary nodules ≤ 30 mm
many factors including nodule density, size, and pleural depth can predict unacceptable rates of surgical detection failure (1). Furthermore,
for NSCLC lesions ≤2 cm in size with N0 disease sub-lobar resection has been shown to be non-inferior in disease free survival when com-
pared to lobectomy (2). Patients previously deemed too debilitated for a definitive resection may now be eligible for surgery and as such
precise localization will become more critical in the coming years.
Previously standard of care for preoperative lung nodule marking included CT-guided transthoracic needle marking (CT-gTTN). Several types
of marking exist in this regard including percutaneous hook wire, coil placement, and dye marking. While there are no direct comparison of
all modalities , several studies have demonstrated similar success rates and procedural time regardless of modality selected. Unfortunately,
these approaches all share a similar incidence of pneumothorax rate and hemorrhage with the highest occurrence in CT-guided hook-wire
placement (3). Additionally, while intraprocedural time is limited, patients often undergo repeat anesthetic events for each phase of care.
Diagnosis, followed by marking, followed by surgery is a near certainty with this method, resulting in delays and complexity of care.
Robotic assisted bronchoscopy (RAB) or electromagnetic navigation (EMN) in conjunction with real time image guidance are new minimally
invasive approaches. Where previously patients with small, peripheral, or ground glass nodules were previously not candidates for EMN or
RAB-marking, newer robotic plaorms and real time image correction have helped overcome CT-to-body divergence. Recent studies have
exhibited comparable surgical resection success to CT-guided transthoracic biopsies (4). Furthermore, the integration of primary lesion diag-
nosis, mediastinal staging via EBUS-TBNA, localization, and subsequent sublobar resection into a single procedural seng theoretically will
minimize the interval between initial clinical presentation and definitive surgical intervention.
Indications:
RAB-nodule localization should be considered for patients with nodules with a high likelihood of intraoperative identification difficulty. Nod-
ules characteristics which increase visualization and palpation difficulty include those that are sub-centimeter, greater than 10mm from the
closest pleural surface, and non-solid nodules (1, 5). Additionally, those planned for sub-lobar resection or where multiple resections are
consecutively considered would benefit from RAB-nodule localization due to its increased safety profile when compared with CT-gTTN. As a
result, patients who have undergone previous surgical lung resections or with abnormal pulmonary function tests should be viewed as po-
tential candidates.
Nodule localization for Minimally Invasive Surgery
Michael Murn, MD
Interventional Pulmolnology
Assistant Professor of Medicine
Assistant Professor of Cardiovascular &
Thoracic Surgery
Division of Pulmonary, Critical Care & Sleep
Medicine
Zucker School of Medicine at Hofstra-
Northwell
Abhinav Agrawal, MD
System Director, Interventional Pulmonology
Asssociate Professor of Medicine
Associate Professor of Cardiovascular &
Thoracic Surgery
Division of Pulmonary, Critical Care & Sleep
Medicine
Zucker School of Medicine at Hofstra-
Northwell
Tips from the Experts
P A G E 8 V O L U M E 1 3 , I S S U E 1
Planning
We perform robotic bronchoscopic biopsy utilizing one of several RAB plaorms currently on the market. Pre-procedural planning and navi-
gation is completed using a pre-procedure thin-slice CT scan of 1mm or less ideally collected as close to the procedural data as feasible. This
allows for a more representative 3D reconstruction of the patients’ airways, pleural borders, and target lesion, improving safety as well as
accuracy of target mapping. For nodules within 20mm of the pleural border, a virtual target within the 3D planning software will be made at
the lesion. For nodules greater than 20mm from the pleural border, a superficial virtual target will be made at 10mm from the closest pleural
border. The interval between RAB-marking and resection is crucial in selecting between dye and fiducial placement as dye marking loses visu-
alization efficacy after 24 hours (6). For deeper and ground glass lesions pre-procedural collaboration with the performing thoracic surgeon is
critical to ensure appropriate approach and margins are selected based on the ideal surgical plan.
Sampling/Technique:
Suggested Dye Marking Mixture
25 mg ICG dye reconstituted in 10mL sterile water. 10mL of methylene blue can be optionally added if felt beneficial by collaborating sur-
geon.
Single Event Marking
In cases where the nodule has already been pathologically confirmed, navigation, using standard technique, is employed utilizing pre-
procedural airway planning to navigate within 30mm of the pre-procedural virtual target. If available, several intraoperative technologies
including rEBUS, augmented fluoroscopy, and cone beam CT (CBCT) can be utilized to overcome CT-to-body divergence. Once confirmation of
the marking target has occurred the RAB bronchoscope is positioned approximately at 10mm from the virtual target. A 21g needle is primed
with indocyanine green (ICG) and methylene blue mixture. Following this the needle is deployed under fluoroscopic guidance and direct con-
tact of the needle with lung parenchyma is visually confirmed. Once the needle is confirmed in satisfactory position, 0.3mL of the dye mixture
is injected. Further markings are completed if required after no intraprocedural pneumothorax is confirmed with real time imaging (i.e. fluor-
oscopy, CBCT). Following successful marking, the patient is prepared for surgical resection by airway exchange to double-lumen tube and
thoracic surgery team proceeds with resection. 10mL of methylene blue can be added, which is visible to the naked eye, allowing for localiza-
tion even if robotic surgery cannot be performed due to technical challenges (Fig. 1a-b).
Staged-Event Marking
When the diagnosis of the nodule is uncertain, and resection will be completed in staged fashion, a fiducial marker can be placed for a more
durable indicator. Following navigation and malignancy confirmation via rapid on site cytologic evaluation, we proceed with fiducial place-
ment. To complete this, we typically create a ICG dye mixture of 25 mg ICG dye and 10mL sterile water. At this point, 0.5mL of this mixture
will be injected into a Cook Tornado Coil (Cook Medical LLC, Bloomington, IN, USA) for 15 minutes to allow absorption unto the coil fibers.
Finally, we load the Cook Tornado Coil into a delivery catheter. Deployment is completed in a similar fashion to single-event marking de-
scribed above under fluoroscopic guidance (Fig. 1c-d).
Quality control:
RAB-nodule localization increases the technical expertise required for a successful and time-efficient procedure. As a result, bronchoscopists
and thoracic surgeons should undergo formal training with the intended plaorm prior to implementation. Furthermore, visualization of ICG
marking requires Firefly fluorescence imaging system (da Vinci Fluorescence Imaging Vision System) or equivalent system. While ICG is rou-
tinely used, the proceduralist should be aware of the small possibility for allergic reaction, and this should be evaluated for during pre-
procedural consultation. While a significantly safer risk profile for RAB-nodule marking than CT-gTTN marking, the potential for pneumotho-
rax (0.5% vs 14%, p<0.001) and bleeding (4.1% vs 15.4%, p=0.005) still exists and should be monitored for prior to case termination and pa-
tient disposition (4).
Tips from the Experts
P A G E 9 V O L U M E 1 3 , I S S U E 1
Conclusion
RAB-nodule localization offers a minimally invasive approach for pre-operative localization of challenging pulmonary nodules, particularly for
sublobar resections in early-stage lung cancer patients. Using advanced imaging and navigation, RAB allows for precise dye or fiducial marker
placement, and can even be combined with diagnostic procedures like biopsy and mediastinal staging, within a single procedure. This tech-
nique demonstrates a superior safety profile compared to traditional CT-guided percutaneous marking, reducing risks of pneumothorax and
hemorrhage while streamlining the time from diagnosis to surgical intervention.
References:
1. Suzuki K et al. CHEST. 1999 Feb 1;115(2):563–8
2. Altorki N et al. N Engl J Med. 2023 Feb 8;388(6):489–98.
3. Park CH et al. Chest. 2017 Feb;151(2):316–28.
4. Du J et al. Wideochir Inne Tech Maloinwazyjne. 2022;17(4):601-610.
5. Saito H et al. J Thorac Cardiovasc Surg. 2002 Dec 1;124(6):1198–202.
6. Rho J et al. Ann Surg. 2021 May 1;273(5):989–96.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
The Interventional Pulmonology Institute
Happy Birthday
Written by : Ömer Ayten, Cengiz Özdemir, Levent Dalar, and Ali Musani
The World Association for Bronchology and Interventional Pulmonology (WABIP) is a nonprofit organization with 60 Inter-
ventional Pulmonology (IP) societies and 10,500 members dedicated to education and training in bronchoscopy and IP
worldwide. For the last few decades, WABIP has played a significant role in raising the expertise in bronchoscopy and IP
through workshops, webinars, global conferences, and numerous educational products.
However, despite these efforts, the IP field remains nonexistent or primitive in large parts of the world, except in Western
countries and a few Asian countries with access to advanced technology, formalized training, and resources. IP training, re-
sources, and infrastructure are unavailable in many countries, especially those with lower socio-economic status. As a result,
much of the world's population cannot benefit from the diagnostic and therapeutic advances in pulmonary medicine. Doc-
tors from developing countries face insurmountable barriers in pursuing IP training, such as pre-certification in medicine or
surgery and pulmonary and critical care, local licensure, and malpractice insurance to train in countries with well-established
IP and IP training programs. Short courses and informal observerships or apprenticeships, once the only viable options for
training, have become increasingly unfeasible due to various reasons, including host countries' policies for international doc-
tors, visa restrictions, language barriers, and financial constraints.
In response to these challenges, WABIP introduced a unique concept by combining multinational for-profit and nonprofit
organizations to provide state-of-the-art training to doctors worldwide. The training includes a didactic and hands-on curric-
ulum developed by world leaders in IP under the auspices of WABIP. This fellowship is offered at private and government
hospitals in Turkey, Greece, Italy, and Spain. The partnership provides multicenter simulation and hands-on and didactic
training. After months of intense training, a didactic and hands-on certification examination is conducted by the Internation-
al faculty of the WABIP before granting a certificate of completion to the fellows.
This program was formalized in April 2023 under the Interventional Pulmonology Institute (IPI). Dr. Ali Musani was named
the first Chair of the Institute, acknowledging his vision and tireless efforts in establishing the institute. Dr. Levent Dalar was
named the first Director of the IPI-Istanbul, where he has been instrumental in developing the institute, its educational mis-
sion, and its day-to-day operation.
The IPI is housed in LIV Hospital Vadi Istanbul, which generously provided WABIP with the space, instruments, training facili-
ties, and institutional privileges for trainees to treat patients under supervision. The Istinye University, Istanbul, accredits the
IPI. The quarterly fellowship started in October 2023 and received four times as many applications as the available training
spots worldwide. These applications are reviewed by a dedicated international faculty led by Professor Javier Flandes from
Spain. One of the primary criteria for selecting trainees includes whether there is a center in their country where they can
establish an IP center to practice the procedures learned during IPI training. Additionally, the selection committee considers
the trainees' potential to start training programs in their own countries, thereby benefiting their communities by elevating
the level of healthcare.
The selected doctors undergo a three-month training program that includes online theoretical lessons provided by experi-
enced WABIP doctors, simulation training in Florence, Italy, and Athens, Greece, and hands-on and case-based training at
various hospitals in Turkey. The Turkish hospitals were chosen for their extensive experience in IP, including Liv Vadi Istanbul
Hospital, Yedikule Chest Diseases and Thoracic Surgery Hospital, Kartal Training and Research Hospital, Eskişehir Osmangazi
University Hospital, Gülhane Training and Research Hospital, Sultan Abdulhamid Han Training and Research Hospital, and
Ankara Atatürk Sanatorium Training and Research Hospital. The multi-institutional training allows trainees to observe a wide
Humanitarian News
W A B I P N E W S L E T T E R P A G E 11
variety of cases and approaches by different physicians. At the end of the training period, those who pass a theoretical and
practical examination under the supervision of WABIP-appointed examiners receive a certificate from WABIP-IPI confirming
the completion of their training.
So far, six doctors from Ecuador, South Africa, India, Bolivia, and Iraq have completed their training and have begun perform-
ing these procedures in their countries, benefiting the local population. Currently, two doctors from Libya and Malaysia are
undergoing training. The IPI has already selected ten doctors out of 86 applicants from Ghana, Peru, Philippines, Sudan,
Egypt, Pakistan, Ethiopia, Lebanon, and Kenya for training in 2025.
The IPI program is a nonprofit educational initiative created solely to serve humanity. Therefore, IPI-WABIP, the institutions,
organizations, and instructors providing the training do not receive any financial gain from this program. The training is en-
tirely based on service to humanity and voluntary participation. Instructors selflessly dedicate their valuable time,
knowledge, and experience to train doctors without seeking any personal benefit. The IPI expenses and scholarships provid-
ed to each fellow are funded by the generous support of industry partners Vathin Medical Instrument Co. Ltd and Olympus
Corporation. We thank the faculty, committee members, and leadership of IPI and WABIP for contributing to this education-
al program's creation and continuation.
WABİP Fellow Selection Committee
Dr. Javier Flandes (Chair) – Spain
Dr. Ali Musani -USA
Dr. Shaheen Islam – USA
Dr. Levent Dalar – Turkey
International Faculty (Weekly Zoom Lectures)
Dr. Ali Musani -USA
Dr. Grigoris Stratakos – Greece
Dr. Lorenzo Corbetta – Italy
Dr. Stefano Gasparini – Italy
Dr. Sujith Cherian – USA
Dr. Javier Flandes – Spain
Dr. Daniela Gompelmann – Austria
Dr. Hervé Dutau – France
Dr. Muzaffer Metintaş – Turkey
Dr. Mohammad Munavvar -UK
Dr. Tudor Toma – UK
Local Faculty from Turkey who train IPI fellows at their hospitals with hands-on training
Dr. Muzaffer Metintas Dr. Aydın Yılmaz Dr. Guntulu Ak Dr. Sevda Sener Comert
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
Dr. Cengiz Ozdemir Dr. Sinem Nedime Sokucu Dr. Ayperi Ozturk Dr. Deniz Dogan
Dr. Ömer Ayten Dr. Kadir Canoglu Dr. Demet Turan Dr. Efsun Gonca Chousein
Signing ceremony for the first Interventional Pulmonology Institute (IPI) between World Association for Bronchology and
Interventional Pulmonology (WABIP) and LIV Vadi Hospital, Istanbul
Dr. Adil Tanık (Medical Director of LIV Vadi Hospital), Dr. Levent Dalar (Director of IPI), Dr. Ali Musani (Chair of IPI), Meri
Istiroti (CEO of LIV Hospital Group), Dr. Mehmet Akif Benk (General Manager of LIV Vadi Hospital)
Humanitarian News
W A B I P N E W S L E T T E R P A G E 13
IPI Advanced Diagnostic and Therapeutic Bronchoscopy Inaugral Course 2023, Istanbul
From right to left: Dr. Levent Dalar (Turkey), Dr. Grigoris Stratakos (Greece), Dr. Mohammad Munavvar( UK), Dr. Lorenzo
Corbetta(Italy), Dr. Ali Musani(USA), and attendees
Hands-on medical thoracoscopy training at Osmangazi University Hospital/Eskisehir
Dr. Guntulu Ak, Dr. Wan Jen Lye)
Humanitarian News
W A B I P N E W S L E T T E R P A G E 14
IPI practical exam based on a real case at LIV Vadi Hospital/Istanbul
(From left to right: Dr. Levent Dalar (IPI Istanbul Director), Dr. Stefano Gasparini (international examiner-WABIP), Dr. Shaun
Maasdorp (IPI fellow), Dr. Omer Ayten (faculty), Dr. Melvy Apaza (performing procedure-IPI fellow)
Hands-on EBUS training at Atatürk Sanatorium Training and Research Hospital /Ankara
(From left to right: Dr. Housnia Jaballah Soudani(IPI fellow), Dr. Ayperi Ozturk(faculty), Dr. Wan Jen Lye (IPI fellows)
Rigid bronchoscopy training on a mannequin at LIV Vadi Hospital /Istanbul
(Dr. Shaun Maasdorp)
WABIP Best Image Contest 2025
Central Airway Diseases
A 60-year-old male with no significant medical history underwent a chest computed tomography (CT) scan
for the investigation of a persistent cough, which revealed nodular calcifications insinuating into the tracheal
lumen. Further investigation with bronchoscopy revealed multiple sessile nodular lesions with spiculated,
hardened consistency, covered by smooth mucosa and projecting into the airway lumen (resembling stalac-
tites), involving the entire anterior and lateral walls of the trachea while sparing the posterior wall (Panel A).
These findings are hallmark features of Tracheopathia osteochondroplastica. Histological analysis of the biop-
sy confirmed the diagnosis, demonstrating intact respiratory epithelium with submucosal ossification (Panel
B). The patient has remained oligosymptomatic during subsequent follow-ups, with no recorded complica-
tions.
Credits / Image courtesy of
Dr. BIANCA FIDELIX ESPINDULA
Best Image Contest
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This image is 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2024. Our next
Image Contest will open later this year. We look forward to receiving your image submissions.
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WABIP News
A Resounding Success: WCBIP/WCBE 2024 Ignites Bali with Innovation and Collaboration
The 23rd World Congress for Bronchology and Interventional
Pulmonology / World Congress for Bronchoesophagology
(WCBIP/WCBE) in conjunction with the 17th National Congress
of the Indonesian Society of Respirology (ISR) concluded on a
high note, leaving a lasting impression on the global bronchol-
ogy community. Held from October 23-27, 2024, at the Bali
Nusa Dua Convention Center, the congress embraced the
theme "A Magical Blend of Learning: Science, Culture, and Na-
ture," perfectly encapsulating the unique experience offered
to attendees. The 23rd WCBIP/WCBE itself was held between
October 23-25, 2024.
Under the leadership of Congress President Prof. Menaldi Rasmin, and expertly organized by The In-
donesian Society of Bronchoscopy and The Indonesian Society of Respirology, WCBIP/WCBE—ISR
2024 attracted a remarkable 2,123 participants. The event was a hub of knowledge exchange, featur-
ing a diverse program that included workshops and a symposium. The WCBIP/WCBE Workshop drew
297 participants, while the WCBIP/WCBE—ISR 2024 Symposium saw an impressive attendance of
1640. An additional 186 participants engaged in the ISR Workshop.
A Global Gathering of Experts
The congress benefited from the insights of a distinguished Scientific Advisory Board, including Stefa-
no Gasparini (Italy), Atul C Mehta (USA), Gary Lee (Australia),
Henri Colt (USA), Herve Dutau (France), Hideo Saka (Japan),
Jamalul Azizi (Malaysia), Philippe Astoul (France), Rita Rogayah
(Indonesia), and Sita Laksmi Andarini (Indonesia).
The International Scientific Officers, comprising Masahide Oki
(Japan), Septimiu Murgu (USA), Semra Bilaceroglu (Turkey),
Kaid Darwiche (Germany), David Hsia (USA), Philip Emmanouil
(Greece), Lina Zuccatosta (Italy), Fraser Millar (Scotland),
Jamsak Tscheikuna (Thailand), Jamalul Azizi (Malaysia), and
Hari Kishan (India), further enriched the scientific discourse.
Showcasing Cung-Edge Research
The congress received a total of 535 abstract submissions, with 430 accepted for presentation. The
quality of research presented was exceptional, highlighting the significant advancements in bronchol-
ogy and interventional pulmonology. Of the 82 accepted oral presentations, 66 were delivered (80.5%
attendance), and 281 of the 348 accepted poster presentations were showcased (80.8% attendance).
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WABIP News
Recognizing Excellence
The WCBIP/WCBE Oral and Poster Presentation Awards celebrated outstanding contributions to the field.
The following individuals were recognized for their exceptional work:
WABIP Awards
• The WABIP Awards honored distinguished individuals for their lifetime achievements and contribu-
tions to the field:
• The Gustav Killian Centenary Medal: Hideo Saka
• The WABIP-Dumon Award: Jamalul Azizi Abdul Rahaman
• The WABIP Distinguished Regent Award: Lamiya Chrif Morand
Video Festival Highlights
The Video Festival showcased innovative techniques and compelling case studies. The winners in each
category were:
• Best Scientific Content: Dr. Yen Shen Wong - "Malignant Central Airway Obstruction in Pregnancy"
• Best Innovation: Dr. Viswesvaran Balasubramanian - "Bronchoscopic recanalization of complex com-
plete tracheal stenosis with Montgomery t-tube insertion and follow up – A case study"
• Best Imaging: Dr. Viswesvaran Balasubramanian - "Bronchoscopic closure of post lobectomy bron-
chopleural fistula with atrial septal occlusive device – A case report"
• Best Overall: Dr. Viswesvaran Balasubramanian - "Bronchoscopic Recanalization of Complex Complete
Tracheal Stenosis with Montgomery T-Tube Inser"
A Legacy of Progress
WCBIP/WCBE - ISR 2024 in Bali was a resounding success, fostering col-
laboration, showcasing groundbreaking research, and recognizing excel-
lence in the field of bronchology. The congress has undoubtedly left a
lasting legacy, inspiring continued progress and innovation in the years
to come. The WABIP extends its hearelt congratulations to all award-
ees, presenters, and participants for making this event a truly memora-
ble one. We look forward to building upon this success at future con-
WCBIP/WCBE Oral Presentation Awards:
• Junfeng Huang (China)
• Karin Klooster (Netherlands)
• Daniel Sterman (United States)
• Hayoung Seong (South Korea)
• Indalecio Carboni Bisso (Argentina)
WCBIP/WCBE Poster Presentation Awards:
• Belgundi Preeti Vidyasagar (India)
• Daragh Crowley (Ireland)
• Kemas Rakhmat Notariza (Indonesia)
• Long Liang (China)
• Ales Rozman (Slovenia)
Bronchoscopic Lung Volume Reduction: It’s a Process, Not an Event
Treating emphysema with Bronchoscopic Lung Volume Reduction (BLVR) techniques, such as endobronchial valves, is one of the most complex
procedures performed by interventional pulmonologists. While the technical aspect of deploying valves in preselected airways may not demand
significant expertise, the procedure becomes intellectually challenging due to the extensive pre-operative workup required, the post-operative
evaluation of outcomes, and the management of complications. This challenge is further amplified by the elderly and inherently ill patient popula-
tion.
Initially, the advent of BLVR was met with high expectations. Many assumed that bronchoscopy schedules would be filled with BLVR procedures
and that most patients would experience dramatic symptom improvement following a relatively simple intervention. Early concerns focused pri-
marily on the risk of pneumothorax, expected to occur in about a quarter of cases. However, reality proved more nuanced.
Despite severe COPD being prevalent, most patients are not suitable candidates for BLVR due to comorbidities like pulmonary hypertension, bron-
chiectasis, asthma, and other cardiopulmonary diseases. Even in patients who undergo the procedure after rigorous pre-operative evaluation, not
all develop target lobe atelectasis or show symptomatic and objective improvements.
Recently, multiple publications in the Journal of Bronchology and Interventional Pulmonology (1,2) have highlighted the nuances of interpretation
of pre-operative testing, namely echocardiogram for the diagnosis of Pulmonary Hypertension (PH) and dealing with the lack of immediate lobar
collapse/atelectasis and subjective and objective improvement.
Studies like these are critical in adopting novel technologies and allow for a refinement of understanding the physiology and pathology of the dis-
ease and expected outcomes with interventions. The lack of such longitudinal critical analyses of factors involved in the “perceived” failure of the
procedure poses a threat to the novel technologies.
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief WABIP
Newsletter
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsletter@wabip.com
P A G E 18
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Septimiu Murgu
Ali I. Musani MD, FCCP
Professor of Medicine and Surgery,
University of Colorado School of Medi-
cine, Denver
In one of the publications (1), the authors discuss echocardiography as the initial screening tool for PH and the Right Ventricular Systolic
Pressure (RVSP) used as the surrogate for the Mean Pulmonary Artery Pressure (mPAP) measured by Right Heart Catheterization (RHC). An
RVSP cutoff value of 45mm Hg was used for BLVR. Patients above an RVSP of 45 have been rejected for BLVR, assuming their mPAP is above
40 mm Hg. Echocardiography interpretation is often questionable and erroneous in patients with severe pulmonary diseases like COPD.
Many previous studies in PH have shown that in group three, PH patients, the correlation between the RVSP measured on echocardiography
and PAP on RHC is the weakest. Many patients are denied BLVR if their RVSP is greater than 45, which often is their last hope if they are not
a candidate for a lung transplant. Mahajan et al. raise a great point and question the validity of the cutoff of 45 RVSP on echocardiography in
severe COPD patients. Their cohort of more than 450 patients shows that in 88% of patients with RVSP above 45, the mPAP on RHC was ac-
ceptable (<40 mm Hg) for BLVR. Hence, echocardiography is not a good test for establishing PH in patients with severe COPD. It may be a
good test to rule out significant PH when RVSP is under 45, but it is not a good “rule in test” for significant PH when RVSP is greater than 45.
Anyone with RVSP above 45 should be offered an RHC before denying BLVR.
Another publication by Mahajan et al. l (2) discusses the troubleshooting of the lack of immediate atelectasis after BLVR. It is a relatively
common multi-factorial problem that requires a very thoughul analysis. The factors involved in the lack of immediate atelectasis could in-
clude valve migration or poor placement and unidentified or new collateral ventilation, to name a few. This study reviews the incidence and
outcomes of revision bronchoscopies in patients who lost or never achieved target lobe atelectasis following BLVR (20% of all BLVR patients).
The study found that air leaking around the valves, either improper sizing or a change of the airway configuration after valve placement, was
the most crucial reason for the inability to achieve atelectasis or loss of atelectasis. When these issues were resolved with another bronchos-
copy and valve placements, 70% of these patients successfully developed target lobe atelectasis.
This study lends credence to the concept of BLVR being a process, not a one-and-done procedure. In case of failure to attain or maintain
target lobe atelectasis, a thorough workup including repeat CT chest, post BLVR analysis (StratX), bronchoscopy should be considered, and
valve replacement should be considered if indicated.
The above studies show that BLVR is a complex process that requires a thoughul and analytical approach to patient selection and post-
procedure management of apparent failure to achieve the goal of immediate atelectasis of the target lobe. Management of complications of
the procedure, such as persistent pneumothorax and its attendant issues, should be handled with a multispecialty team of IP and thoracic
surgery.
References:
1. Mahajan AK et al. J. Bronchol. Interv. Pulmonol.2025 Jan. 32(1):e0997
2. Mahajan AK et al. J. Bronchol. Interv. Pulmonol. 2025 Jan. 32(1):e1002
Research
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WABIP ACADEMY- WEBCASTS
The WABIP has started a new education project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and interventionalists.
Current webcast topic: Tissue acquisition for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: http://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org International educational website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step testing and assess
ment tools
www.aabronchology.org American Association for Bronchology and I
nterventional Pulmonology (AABIP)
www.eabip.org European Association for Bronchology and
Interventional Pulmonology
W A B I P N E W S L E T T E R
Links
www.chestnet.org Interventional Chest/Diagnostic Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educational and
scientific research information 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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