David Spigel, MD: We’ll start with the first case. Let me walk you both through this. This is a 57-year-old woman who’s a nonsmoker, which is probably not [the majority of the patients] for the 3 of us who operate in a tobacco region in the Carolinas and Tennessee. This patient was found to have ground-glass opacity in the right upper lobe in 2016. Five years later, this imaging showed presence of a dense, nearly 3-cm lesion, so not just a wispy abnormality, but a defined lesion in the right upper lobe. Bronchoscopy revealed adenocarcinoma. Further imaging included a PET [positron emission tomography]–CT [computed tomography] scan, which did not show any evidence of distant disease. This patient underwent a right upper lobectomy, which again revealed adenocarcinoma with negative margins, but also negative nodal involvement. There were no other signs of maybe a more aggressive cancer, no LVI, lymphovascular invasion, or visceral pleural involvement. The EGFR status was unknown.

Dr Singh, I’ll start with you on some basic things to talk about. When I meet patients perhaps not from my system, and I see they’ve had a bronchoscopy, I always wonder whether it’s like what happens at our center, where we do navigational bronchoscopy and are able to get really good samples of tumors? Talk a bit about your approach to the different technologies and working [patients] up. At least at my center, we’ve shifted away from our surgeons in terms of [them] getting us tissue and a diagnosis. We’re looking for our pulmonologist to do that. But Dr Singh, talk about how you approach that initial evaluation.

Jaspal Singh, MD, MHS: Thanks, Dr Spigel, for teeing me up with that good question. There is a lot of variability obviously. This is a huge issue in our country right now to figure out, the variability is almost astronomical. This can start in many different ways, depending on the community that you’re in. I’m part of a large health system. I used to say that my job was actually medical director of pulmonary oncology quality. We struggle with this, because I work at a center that has a lot of bells and whistles. I have navigational [bronchoscopy], but I also have robotic-assisted navigational bronchoscopy. It’s the frontier now for the entire lung. Minimally invasive biopsy is potentially at our doorstep. It’s great, but it’s not the reality in many centers. People who might be in the audience, for example, may not have access to these things.

Through robotic bronchoscopy—I did a few today, for example—we can do all kinds of biopsies for cytology alone, but also for these types of ground-glass opacities. This [patient’s lesion is] dense, but you can use a variety of different tissue tools to acquire that lesion, anything from needles to forceps, now even with a cryoprobe where you get larger pieces of tissue. So tissue volume, histologic architecture, immunostaining, and molecular testing for minimally invasive biopsies is well within reach through bronchoscopy in many centers, and it’s expanding.

That being said, many places don’t have that. So then you have to start thinking, what can I do to accomplish my goals? This situation is potentially a stage I disease. We have to figure out, do we need to do a minimally invasive biopsy, or do we trust the other aspects of PET-CT? That’s going to vary from place to place. This is where we have a bit of variability, and we’re still learning in the space. It’s also institutional preference or surgical preference, if a surgeon wants a biopsy vs they don’t need a biopsy. If all roads lead to resection, do you really need to have a biopsy? These are things we’re still struggling with. Just because we can, should we?

Now, this lesion is borderline, up to the point where in our center and with the guidelines, at 3 cm in 1 dimension, we probably should do invasive staging of the mediastinal preoperatively. That’s where in bronchoscopy, that 3-cm mark from a system perspective is our hard stop. You might say it’s our quality metric. At that point, 3 cm is where we educate our oncology community to say, we need to at least consider invasive mediastinal nodal staging if we can, if it can’t be done surgically. For patients who are nonsurgical candidates, hilar node staging [should be done] as well, to make sure that our radiation oncology colleagues can obtain the information they need to proceed. And with bronchoscopy, nodal staging is extremely low risk in skilled hands, so that’s a nice dimension to have. The further you get out with the lesion, the harder they are, but we’re getting to very tough areas where we successfully biopsied areas that traditionally had not been accessible to the pulmonology community.

David Spigel, MD: Thanks. [Those are] so many great points.

Transcript edited for clarity.