Susan Garwood, MD, discusses biopsy advancements and the future of techniques in lung cancer.
Susan Garwood, MD
Technological advancements introduced in the field of oncology over the last few years are changing the way lung cancer diagnoses are made, but experts say more practices still need to utilize these techniques instead of standard tissue biopsies. For example, electromagnetic navigation bronchoscopy is gaining increasing acceptance as a diagnostic tool for lung cancer.1 The bronchoscopic technique uses a global positioning system designed to produce accurate navigation to peripheral pulmonary target lesions. This can be used as a biopsy of peripheral lung lesions, pleural dye marking of nodules for surgical wedge resection, placement of fiducial markers for stereotactic radiotherapy, and therapeutic insertion of brachytherapy catheters into malignant tissue.
Moreover, endobronchial ultrasound is another advancement that has had a positive impact on the field.2 Endobronchial ultrasound mini-probe allows the multilayered structure of the tracheobronchial wall to be precisely analyzed more effectively than fluoroscopic guided biopsy. The endobrochial ultrasound-transbronchial needle aspiration is utilized for mediastinal lymph node staging of lung cancer, which has also proven to be cost-effective.
“It has revolutionized my practice so much so that this is all that I do,” said Susan Garwood, MD. “I go from traditional pulmonary to really interventional-based diagnoses of lung cancer and staging. It has really been a game changer to shift the stage of lung cancer.”
Garwood, an interventional pulmonologist at TriStar Centennial Medical Center, and Physician Lead, Thoracic Oncology at Sarah Cannon Research Institute, discussed these biopsy advancements and the future of such techniques in an interview during the 2017 OncLive® State of the Science Summit on Advanced Non—Small Cell Lung Cancer.Garwood: I talked about how biopsy techniques really impact patients not only from a diagnosis, but from the importance of how you obtain tissue. We really want to inform those in the medical community about biopsy techniques—specifically,biopsy tools—to get large pieces of tissue with techniques such as navigational bronchoscopy and endobronchial ultrasound. These things, unfortunately, aren’t common all over the nation, but we do have access. It really makes a big difference to expedite care, get a concise evaluation and staging of the patient, and get enough tissue to do molecular testing—which is important to matching best treatment and personalized care with our patients. What impact have you noticed that this has on patients?
To me, this has truly revolutionized my whole career. When I began looking into new diagnostic techniques, it allowed me to realize that diagnosing earlier and shifting the stage of lung cancer required a better tool. Now, we have a better tool with navigational bronchoscopy in the ability to rule out distant disease with things that are safe and concise for the patient. What we have been able to see is that we can get to lesions we have never been able to get to before. So, those early-stage patients who have been in watchful waiting, or for whom we have just been waiting for things to grow, now we can connect them with technology that allows earlier diagnoses. We all know that an earlier diagnosis means a better chance of cure.As we look into screening, we also realize that the same problem exists all over the country with incidental pulmonary nodules that are far more common than those we see with screening. What do we do to make sure that we are not taking patients who don’t have cancer to surgery? We need to be able to apply tools and techniques to help us look deeper into these patients to let us know not only if they’re high risk because of age or smoking, but what else can we find? What else can we look at? Can we look at nasal swabs, blood, or sputum to say, “This patient has lung cancer and we should do something instead of watchful waiting.”
I am very interested in the fact that we are all going to go further together. As we make screening clinics and we connect people who can diagnose, we need to take this huge ocean of incidental findings and be able to whittle it down to those who truly have high risk of having lung cancer. To be able to pinpoint them with proteomics and genomics that allow us to risk stratify those people is really what we are lacking. We need the ability to know who needs a biopsy and who could have lung cancer. What if you’re not a smoker? Nonsmokers aren’t supposed to get lung cancer, but they do every single day. We need better tools. I am very interested in where science is going to lead us. I do think so. As we look at the ability to prognosticate these people, we want to be able to help. If we get them in, our opportunity for smoking cessation rises, and our opportunity to educate about radon rises. We have tremendous ability to talk about the genetics of lung cancer—that it can happen even if you never smoke. It will change the way lung cancer is viewed, and let us really make an impact not only with smoking-related lung cancer, but in a lot of other avenues where people just don’t have it on their radar.We all talk about personalized medicine—targeting our treatments to genetic abnormalities. What about how we biopsy? How do we know that that 1 tiny piece of tissue that we took tells a complete picture? I am very interested in what the tumor and lymph node look like. What is being spilled into the blood? How do we get a complete picture of the genomic and DNA abnormalities in this patient?
We are going to have to dig deeper. Things change. The heterogeneity of tumors is now even more important than ever. Looking at radionics, how do we look at a computed tomography scan and look at the densities? How do we look at the amount that is solid and non-solid? We have such an exciting time in lung cancer that we can look at a picture now and get a better idea of what lung cancer is. We can look at blood, nasal swabs, lymph nodes and tumors, and get a much better idea about anything we can find to match that patient with the best treatment. It is not a one-size-fits-all [approach] anymore; the sky is the limit now. We want the safest biopsy, with the highest yield, with the most impactful and actionable results. In order to do that, we need to pick the most appropriate biopsy location. When we biopsy that patient, we need to biopsy it with the best tool and the best clinician to get enough material not only to diagnose, but to tell us everything we can about the molecular makeup.
It takes communication. This is definitely a team sport. The pathologist can help us. The oncologist can tell us how much tissue we need. The pulmonologist can talk about what is safe, not safe, and techniques that can be done. This, like any other disease I have been involved in, needs a multidisciplinary approach. It is going to take all of us in order to do that, but tissue is the issue. We have to be able to get that diagnosis and get viable tissue to tell us the story—to tell us where to go and what to do.