1 07/30/55 Lung Cancer Center: How to Achieve JCI Prof. Emeritus Sawang Saenghirunvattana M.D Copyright 2012 2 07/30/55 TECHNOLOGY ROADMAP Technology Emphasis valve EBUS – GS AUTOFLUORESCENSE Virtual Bronchoscopy EBUS-TBNA VALVE STENT BALLOON ELECTROCAUTERY, ARGON PLASMA COAGULATION BRONCHOSCOPY BRACHY THERAPY 2005 2006 30/07/55 2007 Copyright 2012 2008 2011 2012 2 07/30/55 3 07/30/55 4 5 07/30/55 Lung Cancer Case 2011-2012 sex Samitivej Hospital Non smoking smoking Bangkok Cancer Center Hospital Non smoking smoking Women 21 69 10 Men 8 17 135 30/07/55 Copyright 2012 5 6 07/30/55 Innovation, Research and Development • Electrocautery to destroy airway cancer Pre ELECTROCAUTERY Post Timing = 30 sec. - 20 min. MR= 0% 7 07/30/55 ARGON PLASMA COAGULATION • TO DESTROY ENDOBRONCHIAL LUNG CANCER 8 07/30/55 Airway Obstruction 07/30/55 9 10 07/30/55 International Invited Presentation In 2007 • Use of bronchial stent in lung cancer.Asia Pacific Congress of Bronchology • 15 Jul 2007. Singapore • 11 07/30/55 Innovation, Research and Development • Balloon occlusion in managing hemoptysis. • Watanabe valve in managing lung bleb and bronchopleural fistula. 12 07/30/55 Innovation, Research and Development • Brachy therapy • Rigid bronchoscopy combination with fiberoptic bronchoscopy 13 07/30/55 Innovation, Research and Development • EBUS 14 07/30/55 • Prof. Noriaki Kurimoto 07/30/55 15 16 07/30/55 Takahiro Nakajima M.D. CHIBA, Tokyo 17 07/30/55 Squamous cell carcinoma 18 07/30/55 Squamous cell carcinoma 19 07/30/55 Squamous cell carcinoma 20 07/30/55 Granuloma 21 07/30/55 Granuloma 22 07/30/55 Metastatic adenocarcinoma 07/30/55 23 Diagnosis and Management of Lung Cancer Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines (2 nd Edition ) W.Michael Alberts Chest 2007;132;1-19 DOI 10.1378/chest.07-1860 24 07/30/55 Initial Diagnosis of Lung Cancer • In patients suspected of having SCLC based on radiographic and clinical finding, it is recommended that the diagnosis be confirmed by the easiest method (sputum cytology, thoracentesis, fine-needle aspirate,bronchoscopy including (TBNA) ,(EBUS NA) , ( EUS-NA ).Grade of recommendation, 1C 25 07/30/55 E-BUS • Effectiveness in Samitivej Hospital 2007 • 94 % in detecting and staging of lung cancer, TB, Sarcoidosis. • MR=0% • European respiratory society, 2007 = 91 % 26 07/30/55 International Invited Presentation In 2007 Managing lung cancer. Asia Pacific Pulmonary Conference, 2 Dec 2007, Australia 27 07/30/55 Endobronchial Ultrasound-guided Transbronchial Needle Aspiration • 2007 Sawang Saenghirunvattana , M.D. N = 50 21 = TB 14 = CA LUNG 1 = Malignant Lymphoma Sensitivity = 96 % 15 th WCB 2008 TOKYO , JAPAN 28 07/30/55 • Invited speaker EBUS TBNA • Annual meeting Japan Society for Respiratory Endoscopy • Jun 17 ,2011 29 07/30/55 Silver Award Virtual Bronchoscopy. European Respiratory Society 17 Sep 2007.Sweden 30 07/30/55 Sawang Saenghirunvattana, M.D. 31 07/30/55 Respiratory Tract 32 07/30/55 Image Comparison 33 07/30/55 Ultrasonic Miniature probes (Mini-Probe) Mini-Probes “mechanical radial scanning miniature probes” Can be passed down the channel of a standard endoscope to provide high quality ultrasound images. 07/30/55 34 Endobronchial Ultrasonography with a Guide Sheath (EBUS-GS) EBUS-GS is another new technique for obtaining specimens in suspected peripheral lung cancer. 07/30/55 35 Endobronchial Ultrasonography with a Guide Sheath (EBUS-GS) US Probe 36 07/30/55 The Advantages • Locate peripheral pulmonary lesions. • Increase the reliability of collection from lesions. • Reduce procedure time by enabling physicians to return to the same lesion or site easily for multiple biopsies. • Reduce damage to the bronchial wall with forceps passed through the sheath. • Reduce radiation exposure since continued fluoroscopy is not necessary once the Guide Sheath position has been fixed. • Improve the diagnostic rate for small lesions. • Diagnose early lung cancer invasion. 37 07/30/55 Diagnostic yield affected the location of the lesion. Kurimoto N et al. Chest 2004;126:959-965 ©2004 by American College of Chest Physicians 07/30/55 CASE STUDY 38 39 07/30/55 CASE STUDY march 2010 march 2012 07/30/55 Training @ Samitivej Sukumvit Hospital Noriaki Kurimoto, MD(National Hiroshima HP) 40 07/30/55 41 42 07/30/55 Tumor cells 07/30/55 43 07/30/55 44 07/30/55 45 46 07/30/55 Transbronchial biopsy 07/30/55 47 07/30/55 48 07/30/55 49 50 07/30/55 Normal bronchial cells 07/30/55 51 Permanent section of transbronchial biopsy 07/30/55 52 07/30/55 53 Fiberoptic fluorescense in early detection of lung cancer 54 07/30/55 Comparison of staging of the lung cancer in Thailand in percent Deesomchoke 2005 Stage 0 Samitivej 2008 Samitivej 2012 0 6 6 Stage I,II 9.4 25 18 Stage III,IV 90.6 69 76 **ELCC 2012 55 07/30/55 PM4. Patient with a solitary nodule(<3cm) on chest X-ray or CT scan of the chest have diagnosis endpoints documented within 2 months. Target = 100 % Identification of malignant nodule is important because it may represent an early stage of lung cancer, so the patients with pulmonary nodule on chest x ray or CT scan in our program will have diagnosis endpoint within 2 months. Numerator Denominator Original source of measure 30/07/55 Numbers of the patients without a prior diagnosis of cancer ( except non melanoma skin cancer ) with a solitary nodule (<3 cm )on chest X-ray or CT scan of the chest have diagnosis endpoints documented within 2 months of the radiological study Total numbers of the patients without a prior diagnosis of cancer ( except non melanoma skin cancer ) with a solitary nodule (<3 cm )on chest X-ray or CT scan of the chest Data collection from medical record Hospital information system ICD – 10 (R 91) Copyright 2012 55 56 07/30/55 PM 4 : Patients with a solitary nodule (<3 cm) on chest x-ray or CT scan of the chest have diagnostic end points documented with in 2 months Percentage 17/20 Target 100% 44/47 100 80 2 cases : Regular follow up 1 case : loss follow up 2 case : Benign lesion 1 case : Infection 60 85% Refuse further investigation 93.6% 40 Have been diagnosed within 2 months 20 0 Oct-Dec' 2010 30/07/55 Jan-Sep' 2011 Year Copyright 2012 56 57 07/30/55 Result : PM4 Finding Benign N = 67 cases 29 (43.28%) (BOOP, AVM, Bone island, Kissing spurs, Calcified granuloma) No true lesion 22 (32.84%) Infection 12 (17.91% (TB=7.46%)) (TB ,Pneumonia ,Acute bronchiolitis ) Refuse further investigation 3 (4.48%) CA lung 1 (1.49%) Time to diagnosis :average 11.25 days (1 day - 105 days) 30/07/55 Copyright 2012 57 58 07/30/55 Benchmarking with International study The national lung screening trial * N (Cases) 53,454 Samitivej Hospital CCPC Lung cancer 67 Non malignancy 94.5 - 96.4 % 92.54 % Lung cancer 3.52 - 3.97 % 1.49 %** False negative 0.16% - 0.51% 0% *NEJM Aug 4,2011 ,Vol. 365 No.5 The National Lung Screening Trial research team “Reduced LungCancer Mortality with Low-Dose Computed Tomographic Screening” **Lung cancer in our data is less than NLST but there is a group of 3 cases : who suspicious of lung cancer refused future investigation 07/30/55 Copyright 2011 58 59 07/30/55 Applicabilities International benchmark . EBUS-TBNA effectivness 95 % 2. International PR and marketing 3. International training center (EBUS-TBNA ) - University of Delhi 2009,2010 4. Work improvement ( KAISEN ) 1. 5. Affiliated teaching hospital – Chulalongkorn University : Occupational health . – Rungsit University : Lung disease . 60 07/30/55 SWOT Analysis • Strength • Leading private hospital group • Funding • Applicable research Weakness - People - Researchers - Statistician • Poor PR • Evaluation , Reward Opportunity - State of the art technology - International network - JCI Threat - Government hospital - Foreign hospital - Publication 07/30/55 61 Future Research 2012 •Multigene resistant analysis • for proper target therapy 07/30/55 62 07/30/55 63 07/30/55 64 07/30/55 65 • Multidisciplinary care team 66 07/30/55 Tumor conference 17/01/2012 26/01/2012 07/30/55 Innovation, Research and Development 67 07/30/55 Acupuncture 68 07/30/55 Home health care 21/03/2012 visit home oxygen case 69 70 07/30/55 Bereavement 07/30/55 Copyright 2011 70 71 07/30/55 Different cultures grieve in different ways, but all have ways that are vital in healthy coping with the death of a loved one. 07/30/55 Copyright 2011 71 72 07/30/55 07/30/55 Copyright 2011 72 07/30/55 73 07/30/55 74 07/30/55 75 Evaluation • Continuous improvement (kaizen) of the product (EBUS) and process to be one of the best of the world • Patient and family satisfaction 07/30/55 76 Inter-organization multidisciplinary team meeting • Dr.Thelioza (UN Thailand) • Case lung cancer • TB • Sarcoidosis 07/30/55 Domestic-alliance • BNH : Lymphoma • BDMS :Sarcoidosis • Aik udorn :Lung cancer ,TB • SSH : Lung cancer • Aikachol :Hemoptysis • Praram 9 : Lung tumor • Ramkhamhang: Lung disease 77 07/30/55 Potential customer • Bangkok Christian Hospital 78 07/30/55 79 International multidisciplinary team meeting Noriaki Kurimoto, MD -pre-op visit ,intra –op -post –op transfer patient back to Japan 07/30/55 International-alliance • US: Lung cancer • UK: Sarcoidosis • France: Lung cancer • Myanmar: Lung cancer • Bangladesh: TB 80 07/30/55 81 Clinical Care Program Certification (CCPC) LUNG CANCER