Lung Cancer Center: How to Achieve JCI

07/30/55 1 Lung Cancer Center: How to Achieve JCI Prof. Emeritus Sawang Saenghirunvattana M.D Copyright 2012

07/30/55 2 Technology TECHNOLOGY ROADMAP Emphasis valve EBUS GS AUTOFLUORESCENSE Virtual Bronchoscopy EBUS-TBNA VALVE STENT BALLOON ELECTROCAUTERY, ARGON PLASMA COAGULATION BRONCHOSCOPY BRACHY THERAPY 2005 2006 2007 2008 2011 2012 30/07/55 Copyright 2012 2

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07/30/55 5 Lung Cancer Case 2011-2012 sex Samitivej Hospital Bangkok Cancer Center Hospital Non smoking smoking Non smoking smoking Women 21 69 10 Men 8 17 135 30/07/55 Copyright 2012 5

07/30/55 6 Innovation, Research and Development Electrocautery to destroy airway cancer Pre ELECTROCAUTERY Post Timing = 30 sec. - 20 min. MR= 0%

07/30/55 7 ARGON PLASMA COAGULATION TO DESTROY ENDOBRONCHIAL LUNG CANCER

07/30/55 8 Airway Obstruction

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07/30/55 10 International Invited Presentation In 2007 Use of bronchial stent in lung cancer.asia Pacific Congress of Bronchology 15 Jul 2007. Singapore

07/30/55 11 Innovation, Research and Development Balloon occlusion in managing hemoptysis. Watanabe valve in managing lung bleb and bronchopleural fistula.

07/30/55 12 Innovation, Research and Development Brachy therapy Rigid bronchoscopy combination with fiberoptic bronchoscopy

07/30/55 13 EBUS Innovation, Research and Development

07/30/55 14 Prof. Noriaki Kurimoto

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07/30/55 16 Takahiro Nakajima M.D. CHIBA, Tokyo

07/30/55 17 Squamous cell carcinoma

07/30/55 18 Squamous cell carcinoma

07/30/55 19 Squamous cell carcinoma

07/30/55 20 Granuloma

07/30/55 21 Granuloma

07/30/55 22 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

07/30/55 24 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

07/30/55 25 E-BUS Effectiveness in Samitivej Hospital 2007 94 % in detecting and staging of lung cancer, TB, Sarcoidosis. MR=0% European respiratory society, 2007 = 91 %

07/30/55 26 International Invited Presentation In 2007 Managing lung cancer. Asia Pacific Pulmonary Conference, 2 Dec 2007, Australia

07/30/55 27 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

07/30/55 28 Invited speaker EBUS TBNA Annual meeting Japan Society for Respiratory Endoscopy Jun 17,2011

07/30/55 29 Silver Award Virtual Bronchoscopy. European Respiratory Society 17 Sep 2007.Sweden

07/30/55 30 Sawang Saenghirunvattana, M.D.

07/30/55 31 Respiratory Tract

07/30/55 32 Image Comparison

07/30/55 33 Ultrasonic Miniature probes (Mini-Probe) Mini-Probes scanning miniature probes mechanical radial 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

07/30/55 36 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.

07/30/55 37 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 38 CASE STUDY

07/30/55 39 CASE STUDY march 2010 march 2012

07/30/55 40 Training @ Samitivej Sukumvit Hospital Noriaki Kurimoto, MD(National Hiroshima HP)

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07/30/55 42 Tumor cells

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07/30/55 46 Transbronchial biopsy

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07/30/55 50 Normal bronchial cells

07/30/55 51 Permanent section of transbronchial biopsy

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07/30/55 53 Fiberoptic fluorescense in early detection of lung cancer

07/30/55 54 Comparison of staging of the lung cancer in Thailand in percent Deesomchoke 2005 Samitivej 2008 Samitivej 2012 Stage 0 0 6 6 Stage I,II Stage III,IV 9.4 25 18 90.6 69 76 **ELCC 2012

07/30/55 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 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) 30/07/55 Copyright 2012 55

07/30/55 56 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 44/47 Target 100% 100 80 2 case : Benign lesion 1 case : Infection 2 cases : Regular follow up 1 case : loss follow up 60 40 20 85% 93.6% Refuse further investigation Have been diagnosed within 2 months 0 Oct-Dec' 2010 Jan-Sep' 2011 Year 30/07/55 Copyright 2012 56

07/30/55 57 Finding Benign (BOOP, AVM, Bone island, Kissing spurs, Calcified granuloma) N = 67 cases 29 (43.28%) No true lesion 22 (32.84%) Infection (TB,Pneumonia,Acute bronchiolitis ) Refuse further investigation 12 (17.91% (TB=7.46%)) 3 (4.48%) CA lung 1 (1.49%) Result : PM4 Time to diagnosis :average 11.25 days (1 day - 105 days) 30/07/55 Copyright 2012 57

07/30/55 58 Benchmarking with International study The national lung screening trial * Samitivej Hospital CCPC Lung cancer N (Cases) 53,454 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 Lung- Cancer 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

07/30/55 59 Applicabilities 1. 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 ) 5. Affiliated teaching hospital Chulalongkorn University : Occupational health. Rungsit University : Lung disease.

07/30/55 60 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

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07/30/55 65 Multidisciplinary care team

07/30/55 66 Tumor conference 17/01/2012 26/01/2012

07/30/55 67 Innovation, Research and Development

07/30/55 68 Acupuncture

07/30/55 69 Home health care 21/03/2012 visit home oxygen case

07/30/55 70 Bereavement 07/30/55 Copyright 2011 70

07/30/55 71 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

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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 77 Domestic-alliance BNH : Lymphoma BDMS :Sarcoidosis Aik udorn :Lung cancer,tb SSH : Lung cancer Aikachol :Hemoptysis Praram 9 : Lung tumor Ramkhamhang: Lung disease

07/30/55 78 Potential customer Bangkok Christian Hospital

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 80 International-alliance US: Lung cancer UK: Sarcoidosis France: Lung cancer Myanmar: Lung cancer Bangladesh: TB

07/30/55 81 Clinical Care Program Certification (CCPC) LUNG CANCER