San José, Costa Rica. March, 2014.

In pulmonary medicine, specifically thorax oncology, a series of diseases challenge the areas of diagnosis and pathology, indicates Doctor Luis Ugalde G., Pulmonologist at the Clinica Biblica Hospital, who reports the wide scope of procedures available for early diagnosis for lung diseases, which can be treated in a minimally invasive fashion.

Lung. If a person having risk factors such as smoking, a history of other types of cancer or neoplasia (abnormal growths), a family history of the same, or irregularities in blood samples suffers a peripheral lesion recently appearing on a lung, this patient should undergo a biopsy. There are various methods that can be used for this:

1. Thorax surgery to take a pathology sample. Some patients may have difficulties in taking this option due to functional or medical limitations or even simply for economic reasons.
2. VATS or Videothoracoscopy: a more simple procedure in which two incisions are made in the thorax to extract the sample.

Both procedures are good, because they permit a biopsy to be made, however the Clinica Biblica Hospital offers a better option named a Bronchoscopy. The type of Bronchoscopy performed in the Hospital is:

Intervention Bronchoscopy which by indirect method achieves the insertion of bronchoscope with special guides and navigation devices until reaching the lesion to take a biopsy using forceps. The great advantages of this procedure are:

1. It is ambulatory surgery and so it is less invasive.
2. As it is endoscopic, surgical risks are lessened.
3. The cost is less.
4. Performance results are excellent.

If a patient undergoes Intervention Bronchoscopy and the biopsy is positive and part of the lung must be removed, the second step would be thorax surgery. In other words, surgical intervention is only carried out if it is truly necessary, so the patient undergoes less stress.

Lymph Nodes. Along the length of the respiratory tract, the bronchia, neck and other organs, we have lymph nodes which can become inflamed due to diverse causes.

Procedures and techniques exist for the treatment of these with the characteristics of a thorax TAC. Using a Bronchoscope, an ultrasound of the bronchia can be performed in order to determine the correct placement of a needle to obtain:

1. A smear sample (sheets of glass on which the sample is smeared for examination by microscope) which is a good sample although of limited performance.
2. A block of cells, which is the equivalent of a biopsy. Immunohistochemical reactions can be obtained from this biopsy in order to come to a final diagnosis.

The procedure with the bronchoscope ensures that the needle reaches the correct location by using the ROSE technique (from the initials Rapid On Site Examination), which guarantees that the material extracted is appropriate for the pathological diagnosis.

Combination of Procedures:

In some circumstances it is necessary to combine techniques in order to determine whether a case requires surgery based on the international TNM classification (tumor, lymph nodes, metastasis) indicating how advanced a tumor is. As these are ambulatory procedures, it is possible to determine if the patient requires surgical intervention. If this is the case, the patient is then referred to the thorax surgeon and then an oncologist for evaluation.

Other treatable diseases:

Other non-cancerous conditions causing inflammation of the lymph nodes which can also be treated with these procedures are:

• Tuberculosis,
• Sarcoidosis,
• Other infections such as fungi.

Early diagnosis can also be obtained for other causes of non-solid hematological malignancies, such as lymphomas with diffuse growth.

There is a wide scope of action, not just for lung cancer, but also for other lung disorders, which are reflected in x-ray images, in TAC, or in peripheral zones of the respiratory system which could be affected, because these are not seen.

Implementation of Procedures

These types of techniques have been performed in the hospital for some time in and have been evolving. The main difference is that the procedure has now become institutionalized for the following reasons:

• They are performed in an exclusive operating room meeting the standards set in the International Joint Commission.
• Special packages are offered to patients taking into account all costs and treatments.
• These are highly complex procedures as they include general anesthesia, but they are ambulatory which is very comfortable for the patient.
• The procedure lasts approximately one hour, plus an hour of recuperation time before returning home.
• The treatments have virtually no complications, and in case that these should arise, the package includes observation time.

Palliative Methods:

Dr. Ugalde also explains palliative treatments for advanced cases of cancer which are offered by the Hospital Clínica Bíblica.

Tracheal Tumors

These are treated by placement of an endobronchial prosthesis or STENS, which is effected with a rigid endoscope and the use of a special tool to open the trachea for placement of an endotracheal device to maintain a secure and clear airway in an ambulatory fashion, such that the patient no longer feels the sensation of suffocation.

Bronchoscope as an ICU tool

Doctor Ugalde further commented on the uses of the Bronchoscope in providing significant action and assistance in the Intensive Care Unit, for the diagnosis of pulmonary infection. Its uses include bronchial lavage and use as a guide for percutaneous tracheotomies. It also plays an important role in the ICU for those patients with complications associated to respiratory ventilation such as Atelectasis, which is basically the collapse of an area of the lung as a result of the mucus it secretes.

Objective of Making These Treatment Options Known:

Dr. Ugalde emphasizes the importance of patient awareness of the effectiveness of these procedures and ability to opt for less invasive methods which give a true diagnosis.

“An attempt is made to classify and study the patient better so the referral to the surgeon, oncologist or radiotherapist is more exact in cases where thorax surgery is necessary or oncological treatment is required, so giving the patient better treatment options,” indicated Dr. Ugalde.

Other Advantages:

As well as blocks of cells, it is also possible to perform genetic studies, taking into account the tumor’s mutations. Some of these present specific mutations, making them candidates for specific treatments. For example, an Adenocarcinoma without mutations which can be treated with chemotherapy, whereas an Adenocarcinoma with mutations is treated with monoclonal antibodies, with different results. It is necessary to have all the information and thanks to this type of procedure, this becomes possible.

Length of a Bronchoscope.

The average duration of a bronchoscope is one hour. In a more complex or flexible bronchoscope, it is possible this may last a little longer.

Other Procedures Performed:

• Pleural Effusions: Accumulation of liquid in the lung. Dr. Ugalde indicates that procedures to remove this liquid for analysis are also offered.
• Taking of Samples of Pleura: A sample of the tissue surrounding the lung inside and out, in order to take a biopsy.
• Pleural Catheter Placement: In the case of advanced neoplastic diseases, a pleural catheter can be placed for ambulatory home management of pleural effusion in order to improve patient respiration.

Testing of Pulmonary Function:

Procedures offered:

1. Spirometry
2. Lung volume
3. DLCO
4. Bronchial Provocation Test

The tests of pulmonary function help to classify lung disorders such as:

• Asthma,
• Emphysema,
• Chronic Bronchitis,

1. Spirometry:

To make an analogy, when a patient is evaluated by a cardiologist, one of the principal tools used is an electrocardiogram; one of the primary tools of Pulmonology is the spirometer, which is used to determine what type of disease is afflicting the patient and the grade of severity of the condition; this may be asthma, EPOC (chronic obstructive lung disease), etc.

2. Lung Volume:

This is visualized as a diagnostic tool when the spirometer is insufficient to clearing up any doubts. Here the patient’s lung volume is seen and calculated to analyze restrictive diseases or DILD (Diffuse Interstitial Lung Disease: where the lung becomes rigid, losing elasticity). This tool is particularly sensitive for cases of chronic coughing which is unexplained or does not respond adequately to treatment, etc.

3. DLCO:

This is a test in which the patient is given a particular concentration of carbon monoxide, which passes very easily from the lung to the blood, much more so than oxygen. In this procedure, the patient is made to inhale a measured concentration and then exhales, with the concentration of carbon monoxide being measured. In a healthy patient, the exhalation of carbon monoxide will be low, because it this will have passed to the blood. In contrast, in a patient with a disease where the gas does not pass easily from the lung to the blood, the concentration will be high on exhalation.

This is a bad sign which helps to corroborate diseases like DILD and pulmonary fibrosis.

4. Bronchial Provocation Test:

Bronchial provocation is used for the patient with the symptoms of constant coughing while presenting a normal physical examination, normal x-rays and Spirometry tests, negative microbiology results, normal blood samples, and suspected asthma.

The patient with these characteristics has a challenge carefully applied to the lung, with the placement of a substance causing controlled irritation. Asthmatic patients react in an exaggerated fashion to this substance, so the diagnosis of ‘hidden’ asthma is made, which is to say asthma which is not easy to diagnose.

Hospital Clínica Bíblica Leader in Advanced Services of Pulmonary Diseases

Few are the hospitals offering such a wide range of services in the pulmonary area, with such advanced diagnostic capabilities. Dr. Ugalde asserts that the capacity of the Clinica Biblica Hospital to resolve issues using such a multidisciplinary approach and great range of equipment to treat pulmonary diseases makes it market leader in this field.

National Reality

Lung cancer is not one of the most prevalent cancers in incidence in Costa Rica, but it does occupy one of the first places in terms of mortality. Many of the patients with pulmonary afflictions have a very low life expectancy. A general statistic indicates that lung cancer has a very low survival rate of just one year. It is also important to remember that at the moment of diagnosis, more than 50% of patients are already in an advanced state of the disease. The only real option that a lung cancer patient has is early diagnosis and surgery.

There is also the issue of prevention. At present, we are seeing the consequences of lung cancer in people who began smoking 20 years ago, and efforts being made today will have repercussions on the statistics of 2034. This is also a worrying economic issue, as 40% of lung cancer diagnoses is made for people who are economically active, said Dr. Ugalde.

The Importance of Making Effective Diagnostic Methods for Lung Diseases Known:

The offering of these advanced diagnostic methods is made in the hope of diminishing mortality for such a grave disease, which once appearing gives the patient little chance of survival unless the disease is discovered in early stages. Unfortunately, early stage diagnoses occur less than 5% of the time.

There must be more awareness of the measures available to prevent lung disease, such as antismoking practices and healthy lifestyles. Even so, there have been cases of middle-aged women who have never smoked and yet have developed lung cancer due to genetic factors which are becoming more intensely manifest in the Costa Rican population.

Patients with other types of lesions who have already undergone irradiation therapy or who have already been operated upon could also benefit from these procedures, as they represent a less invasive option, and can provide a fast and effective diagnosis.

“It is not just about offering a service, but there is also the human aspect of being concerned about arising clinical social situation and we want people to know there are effective options for diagnosis and treatment of oncological thorax diseases and lung cancer,” assured Dr. Luis Ugalde Gamboa, pulmonoligist.

For enquiries of appointments call 2522-1000 or write to citas@clinicabiblica.com