Interventional Radiology in Pulmonary and Critical Care Medicine

Image-guided thoracic interventional procedures have continued to evolve. Over the past decade, the accepted have continued to be refined and re-invented, and the emerging have experienced tremendously quick diffusion of innovation, crossing specialty divides. Certainly, advancements in imaging and technology have been highly visible and easily citable factors but, more poignantly, the spirit of innovation in the individual and collective and their acceptance of and application of new and emerging technologies have been the true driving force behind this movement. The benefit is clearly and increasingly evident in daily practice, specifically in pulmonary and critical care medicine, the focus of this issue.

As illustrated within this issue, percutaneous procedures no longer dabble in only diagnosis but have increasingly moved to therapy, early as evidenced with management of complicated and malignant pleural disease and recently with the emergence of radiofrequency ablation and other thermal energies, specifically microwave and cryoablation, for the treatment of pulmonary malignancies—on many occasions offering palliative and curative therapies to those previously omitted. Fiberoptic applications have also been continually refined and expanded, beneficiaries of the technologic evolution with improvements in stent technology, incorporation of sonography, and blending of computed tomography and bronchoscopy.

Beginning with image-guided diagnosis, Elizabeth Moore provides a thoughtful review of percutaneous transthoracic needle biopsy from a different perspective, that of the ordering clinician; her article reviews the rationale for the imaging evaluation of lung lesions and all details of percutaneous needle biopsy. Matthew Cham and colleagues deliver an excellent overview of special techniques and a nice pictorial for the reader of the spectrum of pulmonary parenchymal targets that can be diagnostically accessible today, many of which previously percutaneously occult, offering insight into the operator's mind and decision-making. Facing similar difficulty, Kamran Ahrar et al serve up a well-thought and insightful review, regarding access to not only pleural but the often difficult or previously inaccessible mediastinal and hilar targets, precluding the need for more invasive surgical tacts. On the molecular level, the rise of novel amplification techniques and other tools provides new ability to study important molecular events on a small clinical sample, such as those provided by core needle biopsy, to more accurately characterize, stage, prognosticate, and target and follow cancer patients and their therapies. As a result, the ability to obtain adequate tissue from a variety of targets, difficult or otherwise, will become increasingly vital.

Moving from the realm of diagnosis to therapy, image-assisted therapy has grown tremendously relevant, particularly during the past decade. Interventional Oncology, to which it is currently referred, is the emerging frontier in image-guided intervention (IGI), through which minimally invasive, percutaneous or intraoperative, local and regional therapies reduce or eliminate cancer tumor burden assisted by real-time imaging for palliation to cure. As an interventional oncologist, Steven Rose critically appraises radiofrequency ablation for pulmonary malignancies, the most widely studied and applied thermal energy for the percutaneous treatment of lung tumors, both primary and secondary. Elliott Wasser and Damian Dupuy offer a glimpse into the evolving world of thermal technology and its ablative applications, focusing on microwave energy, coinciding with its recent market surge. Edward Lee and colleagues summarize the scope of image-guided intervention in the bronchial and pulmonary arterial and systemic venous systems, highlighting several common interventions, including management of both oncologic and non-oncologic thoracic disease. As a complication of advanced cancer, the management and treatment of malignant pleural disease can be somewhat daunting; Marcelo Spector and Jeffrey Pollak survey both old and new image-guided techniques as well as comparative therapies, providing insight into this continual challenge.

Pleural disease, specifically infection and acute and chronic air leak, pervades daily pulmonary medicine, and as such, contemporary information is hugely valuable and certainly useful from a pragmatist's perspective. Christopher Hampson et al provide an excellent update on the current diagnosis and management of parapneumonic and complicated pleural effusions and empyema, including a proposal for a detailed clinical algorithm. Najib Rahman et al offer valuable guidance, navigating the reader through the current information regarding the basis of decision making for the management of acute and chronic pneumothoraces.

As with Interventional Oncology, Interventional Pulmonary Medicine is a relatively new field of medicine, arising from the current wave of technologic innovations, particularly in fiberoptics with image-guidance, direct and indirect, and the increasing need for palliative and curative therapies. As an interventional pulmonologist, Erik Folch, along with Atul Mehta, comprehensively reviews the advances in endoscopic techniques aimed to the tracheobronchial tree. From the advancement in sonographic technology, Marcus Kennedy and colleagues thoroughly examine the evidence for the use of three ultrasonic techniques pertinent to pulmonary disease: endobronchial ultrasound, endoscopic ultrasound and transthoracic ultrasound.

Overall, this issue is a compilation of many outstanding treatises, offering the reader review, insight, and a glance into the future of image-guided thoracic diagnosis and therapy from the perspectives of interventional radiology and oncology and pulmonology. I would like to thank all of the authors for their sustained efforts and contributions, their shared tremendous expertise hopefully provoking additional and continual thought and stimulating poignant and timely research. I would also like to acknowledge Brian Funaki, the Editor in Chief of Seminars in Interventional Radiology, for his ideas, experience, and guidance during all phases of this process from inception to publication of this issue, and Jonathan Goldin for his mentorship in the spirit of spontaneous volunteerism. And finally to all readers, welcome and please enjoy.