Introduction Treatment of malignant tracheoor broncho-oesophageal fistulas (TOF) using therapeutic bronchoscopy (TB) is not standardised and its outcomes are poorly described. This study aimed to analyse the characteristics of patients treated with TB for a TOF and to identify prognostic factors. Methods We analysed data from 96 patients undergoing TB for TOF entered in the EpiGETIF registry between January 2019 and December 2022. Results The mean age was 61.4 years. Median survival after TB was 2.40 months (95% CI 1.81-3.32). Histology was mainly represented by oesophageal (72%) and lung (23%) cancers and did not influence prognosis (p=0.15), whereas smoking did (2.17 versus 3.32 months for nonsmokers, p=0.04). Patients with poor performance status (Eastern Cooperative Oncology Group >2) had shorter survival (1.99 versus 3.02 months, p=0.04). 69% of patients had already received oncologic treatment, with no difference in survival (3.02 versus 2.21 months for treatment-naive patients, p=0.14). Neither the localisation (trachea 61.5%, left main bronchus 34.4%, other 4.1%) nor the size of the fistulas (23% <5 mm, 20% 5-10 mm, 54% >10 mm) impacted survival (p=0.91 and p=0.83, respectively). An airway stent (AS) was placed in 92.7% of patients, mainly self-expanding metallic stents (45%). Patients treated with both an oesophageal stent and AS had a better prognosis than patients treated with an AS alone (2.88 versus 1.77 months, respectively, p=0.02). Conclusion Survival of patients treated with TB for a TOF is very poor, and is impacted by smoking, performance status and the presence of an oesophageal stent.

INTRODUCTION:Therapeutic bronchoscopy (TB) is considered a safe and effective treatment for patients with malignant central airway obstruction (MCAO). While many factors have been associated with technical success, it does not always translate in clinical success. Few factors to predict clinical response have been described. The objective of this study was to determine predictive factors of clinical success for patients with MCAO undergoing TB. METHODS:We used the multicenter prospective registry EpiGETIF to collect data from patients with MCAO undergoing TB from January 2019 to June 2021. The criterion for clinical success was dyspnea measured on the Borg scale. Patients were classified as super responders if they had an improvement of 4 points after the procedure. Uni- and multivariate analyses were performed to highlight an association between preprocedural features and clinical success. RESULTS:A total of 496 patients from 24 centers met inclusion criteria. The mean preprocedural Borg score was 6.5 ± 2.0 versus 2.2 ± 1.7 postprocedural (mean difference 4.3 ± 2.3). Overall, 302 patients (60.9%) were considered super responders. The only factor associated with super responders in multivariate analysis was a higher baseline Borg score. The only factor associated with non-super responders was a poor performance status and mechanical ventilation. CONCLUSION:Patients show good clinical results following TB for MCAO, influenced positively by a worse pre-procedure dyspnea and negatively by a worse performance status. No other data could help predict the effectiveness of TB, confirming the complexity of the process and heterogeneity of the target population.

Background and Objective: Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB). Methods: In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022. Results: From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality. Conclusion: TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

Background and Objective EpiGETIF is a web-based, multicentre clinical database created in 2019 aiming for prospective collection of data regarding therapeutic rigid bronchoscopy (TB) for malignant central airway obstruction (MCAO). Methods Patients were enrolled into the registry from January 2019 to November 2022. Data were prospectively entered through a web-interface, using standardized definitions for each item. The objective of this first extraction of data was to describe the population and the techniques used among the included centres to target, facilitate and encourage further studies in TB. Results Overall, 2118 patients from 36 centres were included. Patients were on average 63.7 years old, mostly male and smokers. Most patients had a WHO score <= 2 (70.2%) and 39.6% required preoperative oxygen support, including mechanical ventilation in 6.7%. 62.4% had an already known histologic diagnosis but only 46.3% had received any oncologic treatment. Most tumours were bronchogenic (60.6%), causing mainly intrinsic or mixed obstruction (43.3% and 41.5%, respectively). Mechanical debulking was the most frequent technique (67.3%), while laser (9.8%) and cryo-recanalization (2.7%) use depended on local expertise. Stenting was required in 54.7%, silicone being the main type of stent used (55.3%). 96.3% of procedure results were considered at least partially successful, resulting in a mean 4.1 points decrease on the Borg scale of dyspnoea. Complications were noted in 10.9%. Conclusion This study exposes a high volume of TB that could represent a good source of future studies given the dismal amount of data about the effects of TB in certain populations and situations.

Background and objective Expression of programmed death-ligand 1 (PD-L1) in tumour cells (TCs) is predictive of immunotherapy efficacy in non-small cell lung cancer (NSCLC). Small biopsy samples collected by bronchoscopy are often used to diagnose peripheral lung cancer. It is questionable whether these small samples from radial endobronchial ultrasonography (r-EBUS) procedures are representative of PD-L1 expression in TCs.Methods We retrieved data of consecutive patients who had surgery for NSCLC and previous r-EBUS biopsy sampling, from 2017 to 2019 in our centre. PD-L1 expression in tumour cells was categorised as <1%, 1%–49% and ≥50%. PD-L1 expression was compared between r-EBUS samples and surgical specimens.Results Among 1026 patients who had r-EBUS, 521 had a diagnosis of lung cancer on r-EBUS sample. PD-L1 testing was indicated in 356 cases and results were considered contributive in 325 cases (91%). 82 patients with PD-L1 expression in r-EBUS samples had subsequent surgical resection of the nodule and were included in the study. PD-L1 expression was identical between r-EBUS samples and surgical specimens in 67% of cases, with kappa 0.44 (p<0.001). 82% of patients with PD-L1≥50% in surgical specimens were identified in r-EBUS samples. Nonetheless, 31% of patients with no PD-L1 expression in r-EBUS samples had some expression in surgical specimens.Conclusion Small samples obtained by r-EBUS are adequate for assessment of PD-L1 expression in tumour cells, with moderate concordance compared to surgical specimens. Reassessment of PD-L1 expression in larger samples may be useful to guide therapy in patients with no PD-L1 expression in r-EBUS samples.

Introduction: Bronchoscopic treatment of malignant tracheo-or broncho-oesophageal fistula (TOF) is not well standardized and its outcomes poorly known. This study aimed to describe the population of patients undergoing therapeutic bronchoscopy (TB) for a TOF and to identify prognostic factors. Methods: We analyzed data prospectively collected in the French EpiGETIF registry from all patients undergoing TB for a TOF, with or without airway stenting (AS). Results: 96 patients were treated from January 2019 to December 2022. Mean age was 61.4 (±9.5 SD)years old. Median survival after TB was 2.4 months. Histology distribution was dominated by oesophageal (72%) and lung (23%) cancers and did not influence prognosis (p=0.15), while tobacco did (2.2 vs 3.3 months for non-smokers, p=0.04). Patients with an altered performance status (PS>2) had a lower survival compared to others (1.9 vs 3.0 months, p=0.04). 68.8% of patients were pretreated, with no significant difference in survival (3.0 vs 2.2 months for treatment-naïve patients, p=0.14). Fistulas were mostly into the trachea (61.5%) or the left main bronchus (34.4%). 23% of TOF were < 5 mm, 20% 5-10 mm and 54% > 10 mm, without impact on survival (p=0.83). AS was performed in 92.7% of patients, mostly covered self-expandable metallic stents (45%) and silicone stents (44%). Patients who underwent both oesophageal and AS had a better survival compared to patients treated only with AS (2.8 and 1.7 months, respectively, p=0.03). Conclusion: Bronchoscopic treatment of TOF is associated with a poor survival that is related with tobacco use, PS and the absence of an oesophageal stent, but not with histology, previous treatments or the size of the fistula.

Abstract Background Various advanced bronchoscopy methods have been developed to reach peripheral lung lesions (PLL). In a large cohort, we aimed to assess a standardized procedure of first‐line radial‐endobronchial ultrasound (r‐EBUS) and virtual bronchoscopy planner for the diagnosis of peripheral lung cancer. Methods This retrospective, single center study included patients who had r‐EBUS‐guided bronchoscopy for the diagnosis of a PLL between 2008 and 2019. Cases without a final diagnosis of cancer or follow‐up were excluded. Results Between 2008 and 2019, 2735 patients had a r‐EBUS procedure, among whom 1627 had a final diagnosis of cancer and were included in the present study. Over the 12‐year study period, r‐EBUS became the first‐line endoscopic procedure to assess PLL (25% as first‐line bronchoscopy in 2008 vs. 92% in 2019). The frequency of the bronchus sign decreased from 2009 to 2019 (100% to 80%; p = 0.001), whereas US visualization of the lesion remained stable (88%). The median number of biopsies increased from two (2008 to 2014) to four (2015 to 2019) (p < 0.0001), with the same diagnostic efficiency (74% total and 80% when a bronchus sign was present). Of the 651 adenocarcinomas, molecular analysis was possible in 86%. PD‐L1 expression analysis was possible in 81% of cases. During the study period, the lifetime of the radial probe increased from 57 procedures to 77 procedures/probe. Conclusion Because r‐EBUS and VB planner is easy to perform under local anesthesia, inexpensive and efficient it can be used as a first‐line procedure to assess peripheral lung cancer.

BACKGROUND:Stage IIIA/B-N2 is a very heterogeneous group of patients and accounts for one third of NSCLC at diagnosis. The best treatment strategy is established at a Multidisciplinary Tumor Board (MTB): surgical resection with neoadjuvant or adjuvant therapy versus definitive chemoradiation with immune checkpoint inhibitors consolidation. Despite the crucial role of MTBs in this complex setting, limited data is available regarding its performances and the reproducibility of the decision-making.METHODS:Using a large cohort of IIIA/B-N2 NSCLC patients, we described patient's characteristics and treatment strategies established at the initial MTB: with a "surgical strategy" group, for potentially resectable disease, and a "medical strategy" group for non-resectable patients. A third group consisted of patients who were not eligible for surgery after neoadjuvant treatment and switched from the surgical to the medical strategy. We randomly selected 30 cases (10 in each of the 3 groups) for a blinded re-discussion at a fictive MTB and analyzed the reproducibility and factors associated with treatment decision.RESULTS:Ninety-seven IIIA/B-N2 NSCLC patients were enrolled between June 2017 and December 2019. The initial MTB opted for a medical or a surgical strategy in 44% and 56% of patients respectively. We identified histology, tumor size and localization, extent of lymph node involvement and the presence of bulky mediastinal nodes as key decision-making factors. Thirteen patients were not eligible for surgical resection after neoadjuvant therapy and switched for a medical strategy. Overall concordance between the initial decision and the re-discussion was 70%. The kappa correlation coefficient was 0.43. Concordance was higher for patients with limited mediastinal node invasion. Survival did not appear to be impacted by conflicting decisions.CONCLUSIONS:Reproducibility of treatment decision-making for stage IIIA/B-N2 NSCLC patients at a MTB is moderate but does not impact survival.

Background: The diagnosis of organizing pneumonia (OP) often requires histological confirmation. The aim of this retrospective study was to evaluate the diagnostic yield and complication rate of radial endobronchial ultrasound (r-EBUS) for OP. Methods: All patients who had r-EBUS as a first diagnostic procedure for a peripheral pulmonary lesion at Rouen University Hospital, France, between April 2008 and December 2020 were included. Cases without a final diagnosis of OP or follow-up were excluded. Patients, lesions, and r-EBUS characteristics were retrospectively analyzed. Results: 2735 r-EBUS procedures were performed, and 33 cases with final OP could be analyzed. Procedures were performed under local anesthesia in 28/33 cases (85%). Among the 33 final OP cases, 17 were considered cryptogenic, and 16 secondary. The lesions were patchy alveolar opacities in 23 cases (70%), masses or pulmonary nodules in 8 cases (24%), and diffuse infiltrative opacities in 2 cases (6%). A bronchus sign on CT scan was found in all cases. In 22 cases (67%), a histopathological diagnosis was obtained from the r-EBUS samples. In 4 cases (12%), histopathological diagnosis was made by surgery, and in 7 cases (21%) the diagnosis was made based on clinical, radiological, and evolution features. An ultrasound image was found in 100% (22/22) of cases in the r-EBUS positive (r-EBUS+) group vs. 60% (6/10) in the r-EBUS negative (r-EBUS-) group, respectively (p < 0.002). The diagnostic yield of r-EBUS for OP was 67% and increased to 79% (22/28) when an ultrasound image was obtained. The median time between CT scan and r-EBUS procedure was 14 days (3–94): 11.5 days in the r-EBUS+ group and 22 days in the r-EBUS- group (p < 0.0001). No severe complications were reported. Conclusion: r-EBUS, when performed shortly after a CT scan showing a bronchus sign, is an efficient and safe technique for OP diagnosis.

We describe a 36-year-old woman with multiple gastric gastrointestinal stromal tumors, hepatic and lymphatic metastasis, and a mediastinal paraganglioma as a presentation of an incomplete Carney triad. We present our therapeutic approach, with emphasis on the surgical and oncologic specificities of this syndrome.

L’analyse des marqueurs moléculaires théranostiques est aujourd’hui centrale dans la prise en charge des carcinomes pulmonaires. Les cancers broncho-pulmonaires étant dans deux cas sur trois diagnostiqués à un stade avancé, ces recherches se font aujourd’hui fréquemment sur de « petits prélèvements ». La stratégie déployée commence par une caractérisation histopathologique la plus fine possible, y compris sur les biopsies et les prélèvements cytologiques. Les recommandations de l’OMS 2015 permettent aujourd’hui de classer sur biopsie des carcinomes non à petite cellules à inflexion glandulaire TTF1 positifs ou à inflexion malpighienne (p40 positive). Seules les tumeurs non à petites cellules et non malpighiennes peuvent être éligibles à un testing moléculaire. Une stratégie visant à épargner les prélèvements de petite taille va être mise en place. Les tests prioritaires sont ceux correspondant à des molécules autorisées ou accessibles. Pour cela, des lames blanches seront préparées, pour les tests sur coupes histopathologiques (immunohistochimie, hybridation in situ) comme ALK. L’ADN sera extrait afin d’évaluer les autres marqueurs : EGFR en premier associé au non à KRAS. Ensuite les biomarqueurs émergents (HER2, ROS1, RET, BRAF…), voire d’autres marqueurs en cas de potentiel recrutement dans les essais cliniques. Le déploiement des techniques de séquençage de nouvelle génération, avec une approche « tout en un » très sensible permettra d’identifier des clones minoritaires. Enfin, le développement des biopsies liquides va ouvrir la possibilité de suivre l’évolution des clones de résistance sous traitement et de permettre un typage moléculaire lorsque les biopsies sont contre-indiquées ou non productives.

Nowadays, the analysis of theranostic molecular markers is central in the management of lung cancer. As those tumors are diagnosed in two third of the cases at an advanced stage, molecular screening is frequently performed on "small samples". The screening strategy starts by an accurate histopathological characterization, including on biopsies or cytological specimens. WHO 2015 provided a new classification for small biopsy and cytology, defining categories such as non-small cell carcinoma (NSCC), favor adenocarcinoma (TTF1 positive), or favor squamous cell carcinoma (p40 positive). Only the NSCC tumors, non-squamous, are eligible to molecular testing. A strategy aiming at tissue sparing for the small biopsies has to be organized. Tests corresponding to available drugs are prioritized. Blank slides will be prepared for immunohistochemistry and in situ hybridization based tests such as ALK. DNA will then be extracted for the other tests, EGFR mutation screening first associated or not to KRAS. Then, the emerging biomarkers (HER2, ROS1, RET, BRAF…) as well as potentially other markers in case of clinical trials, can been tested. The spread of next generation sequencing technologies, with a very sensitive all-in-one approach will allow the identification of minority clones. Eventually, the development of liquid biopsies will provide the opportunity to monitor the apparition of resistance clones during treatment. This non-invasive approach allows patients with a contraindication to perform biopsy or with non-relevant biopsies to access to molecular screening.