Standard Bronchoscopy With Fluoroscopy vs Thin Bronchoscopy and Radial Endobronchial Ultrasound for Biopsy of Pulmonary Lesions: A Multicenter, Prospective, Randomized Trial

Diagnosis of Peripheral Pulmonary Lesions with Transbronchial Lung Cryobiopsy by Guide Sheath and Radial Endobronchial Ultrasonography: A Prospective Control Study

Objective

We design a prospective control study on the utilization of transbronchial cryobiopsy guided by EBUS-GS (EBUS-GS-TBCB) to diagnose PPLs.

Methods

PPLs were defined as pulmonary nodules or masses with a diameter from 10 mm to 50 mm. PPLs were randomly divided into group EBUS-GS-TBCB and transbronchial biopsy by forceps guided under EBUS-GS (EBUS-GS-TBB).

Results

28 cases were involved in group EBUS-GS-TBCB and 31 cases were in group EBUS-GS-TBB. The mean sizes of PPLs were 30.23 ± 11.10 mm in group EBUS-GS-TBCB and 28.69 ± 8.62 mm in group EBUS-GS-TBB (t = 0.600, p=0.551). The diagnostic yields of EBUS-GS-TBCB and EBUS-GS-TBB were 75% and 64.52% respectively, and the difference between the two groups was not significant (χ ² value = 0.137, p=0.711). If only the first specimen was taken into account, the diagnostic yields from EBUS-GS-TBCB and EBUS-GS-TBB were 64.29% (18/28 cases) and 35.48% (11/31 cases), respectively. The difference was statistically significant by Fisher's Exact Test (χ ² value = 4.883, p=0.038). The total incidence rates of bleeding were 21.43% and 6.45%, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB. The total incidence rates of pneumothorax were 7.14% and 0, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB.

Conclusion

The diagnostic yield of EBUS-GS-TBCB was slightly higher than that of EBUS-GS-TBB for the diagnosis of PPLs. EBUS-GS-TBCB might be useful if only the first sample was taken into account.

Guide sheath versus non-guide sheath method for endobronchial ultrasound-guided biopsy of peripheral pulmonary lesions: A multicenter randomized trial

INTRODUCTION

Guide sheaths (GSs) have been widely used during radial probe endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) of peripheral pulmonary lesions. However, it remains unknown whether a GS enhances the diagnostic yield. We compared the diagnostic yields of small peripheral pulmonary lesions between rEBUS-TBB with and without a GS.

METHODS

In eight institutions, patients with peripheral pulmonary lesions≤30 mm in diameter were enrolled and randomized to undergo rEBUS-TBB with a GS (GS group) or without a GS (non-GS group) using a 4.0-mm thin bronchoscope, virtual bronchoscopic navigation, and fluoroscopy. The primary endpoint was the diagnostic yield of the histology specimens.

RESULTS

A total of 605 patients were enrolled; ultimately, data on 596 (300 in the GS group and 296 in the non-GS group) with peripheral pulmonary lesions having a longest median diameter of 19.6 mm were analyzed. The diagnostic yield of histological specimens from the GS group was significantly higher than that from the non-GS group (55.3% versus 46.6%, respectively; p=0.033). Interactions were evident between the diagnostic yields, procedures, lobar locations (upper lobe versus other regions, p=0.003), and lesion texture (solid versus part-solid nodules, p=0.072).

CONCLUSIONS

The diagnostic yield for small peripheral pulmonary lesions afforded by rEBUS-TBB using a GS was higher than that without a GS.

Diagnostic Yield of Digital Tomosynthesis-assisted Navigational Bronchoscopy for Indeterminate Lung Nodules

BACKGROUND

Navigational bronchoscopy is commonly used to sample lung nodules, with a better safety profile but lower diagnostic yield than computerized tomography-guided transthoracic needle biopsy. The addition of digital tomosynthesis to electromagnetic navigation, using intraprocedural images obtained from a C-arm fluoroscope to identify target lesion location and update navigational guidance, may improve diagnostic yield.

METHODS

Consecutive bronchoscopies using tomosynthesis-assisted fluoroscopic electromagnetic navigational bronchoscopy (F-ENB) at a single institution over a 1-year period were included. The primary outcome was diagnostic yield. A bronchoscopy was defined as diagnostic if pathologic examination revealed malignancy or specific histological findings indicative of lesional sampling with confirmatory 6-month follow-up for benign lesions.

RESULTS

A total of 324 patients with 363 nodules underwent F-ENB between April 25, 2018 and April 29, 2019. The average nodule size was 1.9±1.1 cm, 65% of the nodules were located in the peripheral third of the lung. A bronchus sign was present in 24% of cases. Of the 363 nodules, 299 (82.4%) had lesional findings. At 6-month follow-up, among these 299 nodules, 6 were found to be false negatives and 12 nodules were lost to follow-up. Considering all nodules lost to follow-up as false negatives, the 6-month diagnostic yield was 77.4%. Pneumothorax complicated 8 (2.5%) of cases. There was 1 episode of respiratory failure.

CONCLUSION

This retrospective study suggests the diagnostic yield of F-ENB may exceed that of traditional ENB. Future prospective and comparative studies are needed to confirm these promising data.

Robotic Bronchoscopy for Peripheral Pulmonary Lesion Biopsy: Evidence-Based Review of the Two Platforms

Despite many advancements in recent years for the sampling of peripheral pulmonary lesions, the diagnostic yield remains low. Initial excitement about the current electromagnetic navigation platforms has subsided as the real-world data shows a significantly lower diagnostic sensitivity of ~70%. “CT-to-body divergence” has been identified as a major limitation of this modality. In-tandem use of the ultrathin bronchoscope and radial endobronchial ultrasound probe has yielded only comparable results, attributable to the limited peripheral reach, device maneuverability, stability, and distractors like atelectasis. As such, experts have identified three key steps in peripheral nodule sampling—navigation (to the lesion), confirmation (of the correct location), and acquisition (tissue sampling by tools). Robotic bronchoscopy (RB) is a novel innovation that aspires to improve upon these aspects and consequently, achieve a better diagnostic yield. Through this publication, we aim to review the technical aspects, safety, feasibility, and early efficacy data for this new diagnostic modality.

Flexible Bronchoscopy Biopsy Tools and Techniques to Optimize Diagnostic Yield: A Contemporary Review

Background:

Flexible bronchoscopy is essential in diagnosing many pathologic conditions, and tools such as lavage and biopsies using brushes, forceps, and needles are paramount to success.

Introduction:

Bronchoscopists worldwide are routinely confronted with questions about such tools regarding the type, size, utility, costs, safety, anticipated yield, and others. Does the underlying suspected condition matter to the choice of instruments used? What is the anticipated outcome for benign versus malignant diseases? These and other questions are raised daily by bronchoscopists.

Methods:

Pubmed was reviewed for research in the English language pertaining to diagnostic bronchoscopy. The literature is conflicting on the benefits of the types of tools available. The success of brush biopsies, forceps, and transbronchial needle aspiration is only partially dependent on the size of the instrument used or its other characteristics. Multiple biopsies are needed, and different approaches may be complementary in some circumstances.

Results:

By understanding the factors that involve in a biopsy, the bronchoscopist is more likely to be successful when a crucial diagnosis is mandatory.

Conclusion:

This review aims to be a reference to bronchoscopists everywhere as they contemplate their approach to flexible diagnostic bronchoscopy.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO₂ of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10-12 cm H₂O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis

BACKGROUND

The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.

RESEARCH QUESTION

What diagnostic and staging strategies are most cost-effective for lung cancer?

STUDY DESIGN AND METHODS

A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.

RESULTS

For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.

INTERPRETATION

The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.

Ultrathin bronchoscope combined with virtual bronchoscopic navigation and endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions with or without fluoroscopy: A randomized trial

Background

Transbronchial lung biopsy (TBLB) is usually performed to obtain a definitive diagnosis for peripheral pulmonary lesions (PPLs). Ultrathin bronchoscopy combined with virtual bronchoscopic navigation (VBN) and radial endobronchial ultrasound (R‐EBUS) are generally considered appropriate diagnostic methods for PPLs; however, they have not yet been explored in combination with fluoroscopy. Therefore, the present prospective randomized controlled trial determined the role of fluoroscopy in ultrathin bronchoscopy combined with VBN and R‐EBUS for the diagnosis of PPLs.

Methods

Patients with potentially malignant PPLs were enrolled in the study and randomized into fluoroscopy or nonfluoroscopy groups. In both groups, a 3.0‐mm outer and 1.7‐mm internal diameter ultrathin bronchoscope was used for transbronchial lung biopsy combined with R‐EBUS and VBN. In addition, the fluoroscopy group (FG) underwent fluoroscopy, while the nonfluoroscopy group (NFG) did not.

Results

A total of 126 patients were enrolled and randomized in the study. Among them, 120 patients (60 in the NFG and 60 in the FG) were analyzed. The mean lesion sizes were 26.3 ± 11.4 mm and 29.0 ± 11.3 mm in the NFG and FG, respectively. The diagnostic yield was 73.3% (44/60) in the NFG and 81.7% (49/60) in the FG without statistically significant difference (p = 0.38). No obvious complications occurred in either group.

Conclusions

Ultrathin bronchoscope combined with VBN and R‐EBUS without fluoroscopy is a feasible and safe diagnostic method for PPLs.

Invasive modalities for the diagnosis of peripheral lung nodules

INTRODUCTION

Lung nodules are being increasingly discovered either incidentally or through lung cancer screening chest CT scans. Some of these will turn out to be malignant and therefore it is important to obtain an accurate and timely diagnosis of lung cancer when suspected.

AREAS COVERED

This review will cover various invasive diagnostic modalities available to sample lung nodules. Data from key studies, obtained from PubMed searches, will be reviewed. Emerging technologies such as cone-beam CT and robotic-assisted bronchoscopies will be discussed along with ddata available currently to support their use.

EXPERT OPINION

The best approach to diagnosing a lung nodule - whether found incidentally or because of lung cancer screening - is continuously evolving. While CT-guided lung nodule biopsy has a high diagnostic yield, the risk of pneumothorax is often a concern. Bronchoscopy has a better safety profile, but diagnostic ability falls short of CT-guided biopsy. Existing technologies such as electromagnetic navigation have not demonstrated a high diagnostic yield. Factors responsible for this relatively lower low diagnostic yield will be discussed in detail. Emerging technologies such as cone-beam CT scan and robotic bronchoscopy have addressed some of these issues and initial experience has demonstrated better diagnostic yield.

Prospective Analysis of a Novel Endobronchial Augmented Fluoroscopic Navigation System for Diagnosis of Peripheral Pulmonary Lesions

BACKGROUND

Navigational bronchoscopy has improved upon traditional bronchoscopy to identify suspicious pulmonary lesions, but wide variability exists in the diagnostic yield of various modalities. The aim of this study was to measure localization accuracy and diagnostic yield of a novel endobronchial augmented fluoroscopic navigation system (first-generation LungVision system) for peripheral pulmonary lesions (PPLs).

METHODS

This prospective single-center study included adults undergoing guided bronchoscopy to evaluate PPLs. Preprocedure computed tomography (CT) images were obtained, and planning software calculated a pathway to the lesion. A flexible bronchoscope was used to navigate along the pathway overlaid on the intraprocedural fluoroscopic image. When real-time display indicated the catheter tip had reached the lesion, cone-beam computed tomography (CBCT) was used to measure the actual location of the tip. Biopsy and rapid on-site cytopathologic evaluation were performed.

RESULTS

Fifty-one patients were included in the analysis. The median lesion diameter was 18.0 mm (range: 7.0 to 48.0 mm). Localization success was 96.1%. The average distance between lesion location as shown by LungVision augmented fluoroscopy and actual location measured by CBCT was 5.9 mm (range: 2.1 to 10.0 mm). Diagnostic yield at the index procedure was 78.4%. Diagnostic accuracy assessed at 12 months follow-up was 88.2%. Average CT-to-body divergence was 14.5 mm (range: 2.6 to 33.0 mm) from preprocedure CT to intraprocedural CBCT images.

CONCLUSION

Augmented fluoroscopy for navigation and biopsy of PPLs with the LungVision system showed a high localization success rate and corresponding high diagnostic yield. Navigation and biopsy with real-time visualization can improve diagnostic yield for PPLs.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

Robotic Bronchoscopy for the Diagnosis of Peripheral Lung Nodules: a Review

Purpose of Review

Conventional bronchoscopy has limitations based on an inability to accurately reach and reliably diagnose peripheral lesions with many studies having a yield of less than 50%. Although newer technology such as virtual bronchoscopy, use of smaller bronchoscopes, peripheral endobronchial ultrasound, and electromagnetic navigation may have some improvements and a better safety profile, oftentimes transthoracic or surgical biopsies are required to establish a diagnosis and rule out malignancy. The purpose of this review is to highlight the potential benefits of robotic bronchoscopy, the latest in technological advances for this very common medical issue.

Recent Findings

Recently published early studies suggest the yield of robotic bronchoscopy may surpass 90%. Studies performed in cadavers and humans suggest robotic bronchoscopic platforms are better than currently existing bronchoscopic modalities for lung nodule diagnosis and have a favorable safety profile.

Summary

Although additional multi-center randomized clinical trials are needed, robotic bronchoscopy appears poised to supplement current bronchoscopic techniques for establishing a diagnosis of pulmonary nodules.

Electromagnetic Navigation Bronchoscopy With Tomosynthesis-based Visualization and Positional Correction: Three-dimensional Accuracy as Confirmed by Cone-Beam Computed Tomography

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, anatomic divergence between the preprocedural computed tomography (CT) and the actual bronchial anatomy during the procedure can limit localization accuracy. An advanced ENB system has been designed to mitigate CT-to-body divergence using a tomosynthesis-based software algorithm that enhances nodule visibility and allows for intraprocedural local registration.

MATERIALS AND METHODS

A prospective, 2-center study was conducted in subjects with single peripheral lung lesions ≥10 mm to assess localization accuracy of the superDimension navigation system with fluoroscopic navigation technology. Three-dimensional accuracy was confirmed by cone-beam computed tomography. Complications were assessed through 7 days.

RESULTS

Fifty subjects were enrolled (25 per site). Lesions were <20 mm in 61.2% (30/49). A bronchus sign was present in 53.1% (26/49). Local registration was completed in 95.9% (47/49). Three-dimensional target overlap (primary endpoint) was achieved in 59.6% (28/47) and 83.0% (39/47) before and after location correction, respectively. Excluding subjects with unevaluable video files, target overlap was achieved 68.3% (28/41) and 95.1% (39/41), respectively. Malignant results were obtained in 53.1% (26/49) by rapid on-site evaluation and 61.2% (30/49) by final pathology of the ENB-aided sample. Diagnostic yield was not evaluated. Procedure-related complications were pneumothorax in 1 subject (no chest tube required) and scant hemoptysis in 3 subjects (no interventions required).

CONCLUSION

ENB with tomosynthesis-based fluoroscopic navigation improved the 3-dimensional convergence between the virtual target and actual lung lesion as confirmed by cone-beam computed tomography. Future studies are necessary to understand the impact of this technology on diagnostic yield.

Use of Ultrathin Bronchoscope on a Need Basis Improves Diagnostic Yield of Difficult-to-Approach Pulmonary Lesions

There are cases of peripheral lung nodules that are difficult to approach despite using ancillary diagnostic devices during multimodal bronchoscopy. The use of ultrathin bronchoscopes has shown superiority over standard thin bronchoscopes. We retrospectively evaluated whether substitution of the thin-bronchoscope by the ultrathin device during multimodal bronchoscopy improves lesion ultrasound visualization and diagnostic yield in patients with difficult-to-approach pulmonary lesions. The study comprised 44 out of 338 patients that underwent multimodal bronchoscopy at Matsusaka Municipal Hospital. The thin-bronchoscope with an external diameter of 4 mm was substituted by the ultrathin-bronchoscope with an external diameter of 3 mm when the radial endobronchial ultrasound showed that the probe position was not within the target lesion. The median diameter of the pulmonary tumors was 17.5 mm (range: 6.0-5.2.0 mm). The endobronchial ultrasound showed the probe's position adjacent to the lesion in 12 cases and no visible lesion in 32 cases using a thin-bronchoscope. However, the endobronchial ultrasound views changed from adjacent to the lesion to within the lesion in nine cases, from no visible lesion to within the lesion in 17 cases, and from no visible lesion to adjacent to the lesion in nine cases after bronchoscope substitution. After substitution, the diagnostic yield was 80.8% in cases with the radial probe within the target lesion, 72.7% in cases with the probe adjacent to the target lesion, and 0% in cases with no visible lesion. The overall diagnostic yield was 65.9% after bronchoscope substitution. The substitution of the thin bronchoscope by the ultrathin device on a need basis improves the position of the radial endobronchial ultrasound probe and diagnostic yield of pulmonary lesions during multimodal diagnostic bronchoscopy.

Cone beam CT imaging for bronchoscopy: a technical review

Cone beam computed tomography (CBCT) is a well-established imaging modality with numerous proven applications across multiple clinical disciplines. More recently, CBCT has emerged as an important imaging tool for bronchoscopists, primarily used during transbronchial biopsy of peripheral pulmonary lesions (PPLS). For this application CBCT has proved useful in navigating devices to a target lesion, in confirming device tool-in-lesion, as well as during tissue acquisition. In addition, CBCT is poised to play an important role in trials evaluating bronchoscopic ablation by helping to determine the location of the ablative probe relative to the target lesion. Before adopting this technology, it is key for bronchoscopists to learn some basic concepts that will allow them to have a safer and more successful experience with CBCT. Hence, in the current manuscript, we will focus on both technical and practical aspects of CBCT imaging, ranging from systems considerations, image quality, radiation dose and dose-reduction strategies, procedure room set-up, and best practices for CBCT image acquisition.

Is tomosynthesis an ingenious scheme for bronchoscopic diagnosis of lung nodules?

See related Reply

Bronchoscopic Diagnostic Procedures Available to the Pulmonologist

In the diagnosis of lung cancer, pulmonologists have several tools at their disposal. From the tried and true convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration to robotic bronchoscopy for peripheral lesions and new technology to unblind the biopsy tools, this article elucidates and expounds on the tools currently available and being developed for lung cancer diagnosis.

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Recent developments in advanced diagnostic bronchoscopy

The field of bronchoscopy is advancing rapidly. Minimally invasive diagnostic approaches are replacing more aggressive surgical ones for the diagnosis and staging of lung cancer. Evolving diagnostic modalities allow early detection and serve as an adjunct to early treatment, ideally influencing patient outcomes. In this review, we will elaborate on recent bronchoscopic developments as well as some promising investigational tools and approaches in development. We aim to offer a concise overview of the significant advances in the field of advanced bronchoscopy and to put them into clinical context. We will also address potential complications and current diagnostic challenges associated with sampling central and peripheral lung lesions.

The top 100 most cited articles on bronchoscopy: a bibliometric analysis

Background

Bronchoscopy is applied broadly in the diagnosis and treatment of pulmonary diseases. Over the past few decades, an increasing number of studies about bronchoscopy have been published. However, little is known about their qualities and characteristics.

Methods

All of the databases in Web of Science (including the Web of Science Core Collection, BIOSIS Citation Index, KCI-Korean Journal Database, MEDLINE, Russian Science Citation Index, and SciELO Citation Index) were utilized to identify articles published from 1990 to 2020. The top 100 most cited articles about bronchoscopy were selected for degree centrality analysis and analyses regarding publication time, total citation number, the citation density, time-related flux, first author, published journal, geographic origin, and research theme.

Results

The selected articles were published mainly in the 2000s and 1990s. Citations per article ranged from 731 to 196. The leading country was the USA, followed by the United Kingdom. The most frequently studied themes were bronchoalveolar lavage (BAL) fluid and biopsy. The degree centrality analysis connoted that “BAL, inflammation, diagnosis” had a high degree of centrality in the 1990s, while “diagnosis, BAL, biopsy, prospective” took centre stage in the 2000s.

Conclusions

The time, area, and theme distribution of the 100 most cited articles on bronchoscopy have been thoroughly analyzed. It is noticeable that researches based on BAL and endobronchial or transbronchial biopsies currently plays a major role.

Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT)

Background

The diagnosis of peripheral pulmonary lesions (PPL) continues to present clinical challenges. Despite extensive experience with guided bronchoscopy, the diagnostic yield has not improved significantly. Robotic-assisted bronchoscopic platforms have been developed potentially to improve the diagnostic yield for PPL. Presently, limited data exist that evaluate the performance of robotic systems in live human subjects.

Research Question

What is the safety and feasibility of robotic-assisted bronchoscopy in patients with PPLs?

Study Design and Methods

This was a prospective, multicenter pilot and feasibility study that used a robotic bronchoscopic system with a mother-daughter configuration in patients with PPL 1 to 5 cm in size. The primary end points were successful lesion localization with the use of radial probe endobronchial ultrasound (R-EBUS) imaging and incidence of procedure related adverse events. Robotic bronchoscopy was performed in patients with the use of direct visualization, electromagnetic navigation, and fluoroscopy. After the use of R-EBUS imaging, transbronchial needle aspiration was performed. Rapid on-site evaluation (ROSE) was used on all cases. Transbronchial needle aspiration alone was sufficient when ROSE was diagnostic; when ROSE was not diagnostic, transbronchial biopsy was performed with the use of the robotic platform, followed by conventional guided bronchoscopic approaches at the discretion of the investigator.

Results

Fifty-five patients were enrolled at five centers. One patient withdrew consent, which left 54 patients for data analysis. Median lesion size was 23 mm (interquartile range, 15 to 29 mm). R-EBUS images were available in 53 of 54 cases. Lesion localization was successful in 51 of 53 patients (96.2%). Pneumothorax was reported in two of 54 of the cases (3.7%); tube thoracostomy was required in one of the cases (1.9 %). No additional adverse events occurred.

Interpretation

This is the first, prospective, multicenter study of robotic bronchoscopy in patients with PPLs. Successful lesion localization was achieved in 96.2% of cases, with an adverse event rate comparable with conventional bronchoscopic procedures. Additional large prospective studies are warranted to evaluate procedure characteristics, such as diagnostic yield.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT03727425; URL: www.clinicaltrials.gov.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Randomized Controlled Trials

Randomized controlled trials (RCTs) are considered the highest level of evidence to establish causal associations in clinical research. There are many RCT designs and features that can be selected to address a research hypothesis. Designs of RCTs have become increasingly diverse as new methods have been proposed to evaluate increasingly complex scientific hypotheses. This article reviews the principles and general concepts behind many common RCT designs and introduces newer designs that have been proposed, such as adaptive and cluster randomized trials. A focus on the many choices for randomization within an RCT is described, along with their potential tradeoffs. To illustrate their diversity, examples of RCTs from the literature are provided. Statistical considerations, such as power and type I error rates, are discussed with the intention of providing practical guidance about how to specify study hypotheses that address the scientific question while being statistically appropriate. Finally, the freely available Consolidated Standards of Reporting Trials guidelines and US Food and Drug Administration guidance documents are introduced, along with a set of guidelines one should consider when planning an RCT or reviewing RCTs submitted for publication in peer-reviewed academic journals.

Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial

BACKGROUND

Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown.

RESEARCH QUESTION

What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia?

STUDY DESIGN AND METHODS

We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers.

RESULTS

Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001).

INTERPRETATION

The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov.

Cone beam navigation bronchoscopy: the next frontier

Navigation bronchoscopy has reached a new horizon in its evolution. Combining with real-time imaging modalities, such as cone-beam computed tomography (CBCT) and augmented fluoroscopy (AF), navigation success can finally be confirmed with high degree of accuracy in real-time. With utilization of this modality, additional clinical observations are being made to help address the CT-body divergence problem and further improve navigation accuracy. This review focuses on description of CBCT navigation technique, provide tips on addressing CT-Body divergence, and review evidence for CBCT applications in navigation bronchoscopy.

Evaluating the efficacy of bronchoscopy for the diagnosis of early stage lung cancer

Novel diagnostic techniques for lung cancer are rapidly evolving. Specifically, several novel changes to bronchoscopy are reaching clinical evaluation. It is critical to think about historical standards for evaluating new diagnostic testing, and put those concepts into the framework of lung cancer. Often a thorough evaluation of new technology is not performed as a part of regulatory marketing clearance. Therefore, we must consider how to best study novel testing beyond these regulatory minimums. There are several methodological principles that can achieve this goal such as using a control arm, more thorough reporting of enrolled patients, consecutive patient enrollment, and adequate sample size. We hope clinicians, particularly those performing bronchoscopy for lung nodules, will feel empowered to critically appraise the evaluation of new diagnostic testing for lung cancer moving forward.

Bronchoscopic biopsy of peripheral pulmonary lesions in 2020: a review of existing technologies

There are over 200,000 new cases of lung cancer diagnosed annually in the United States resulting in nearly 150,000 deaths, making lung cancer the most lethal of all forms of cancer. Only 1 in 6 lung cancers are diagnosed at an early stage an over half are diagnosed with distant metastasis. Despite advances in screening and treatment, the 5-year survival rate for all lung cancers remains low, around 20%. The advent of effective lung cancer screening with low-dose computed tomography has started to shift diagnosis to earlier stages. Screening, along with the ever-increasing use of chest CT, have led to an exponential increase in the detection of indeterminate lung nodules. For many nodules, effective diagnosis relies on invasive tissue sample collection. Advances in bronchoscopic technology have allowed for safe and increasingly effective tissue diagnosis of these nodules; however, inconsistencies across studies evaluating diagnostic yield remain. This review will provide an overview of the advanced bronchoscopic technologies currently in wide use, the quality of data supporting their use, some of the perceived weaknesses and strengths of each technology, and introduce promising emerging diagnostic platforms poised to advance the field. Ultimately, quality comparative research is needed to accurately characterize the diagnostic test performance of currently available bronchoscopic platforms, improve the efficacy of bronchoscopy-generated diagnostic yields while maintaining, their strong safety profile.

Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology

CONTEXT.—

The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples.

OBJECTIVE.—

To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies.

METHODS.—

The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered.

RESULTS.—

Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples.

CONCLUSIONS.—

Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

Diagnostic value of the combined use of radial probe endobronchial ultrasound and transbronchial biopsy in lung cancer

BACKGROUND

Although the use of radial endobronchial ultrasound (R-EBUS) with a guide sheath has shown improved diagnostic capability in peripheral pulmonary lesions, its utility is still low due to variable performance. To overcome its limitation, we evaluated the feasibility and efficacy of R-EBUS combined with transbronchial biopsy (TBB) under fluoroscopic guidance.

METHODS

We retrospectively reviewed medical records of 74 patients with non-small cell lung cancer (NSCLC) who underwent R-EBUS combined with TBB or TBB alone as a diagnostic technique. Subjects were grouped according to the diagnostic modality used (R-EBUS combined with TBB vs. TBB alone). Each group was matched for age, sex, and location of the biopsy. The chi-square test and paired t-test were used to compare characteristics and identify factors that affected the diagnostic yield.

RESULTS

The mean age of the study cohort was 67.4 ± 12.8 years, with 21 (56.8%) men and 16 (43.2%) women in each group. The lesion size was significantly smaller in the R-EBUS group (23.6 vs. 33.9, P < 0.001). The diagnostic yield with the combined use of R-EBUS and TBB (27/37, 72.9%) was significantly higher than that with standard TBB alone (22/37, 59.4%). Lung lesions with a positive bronchus sign were associated with a higher diagnostic yield (odds ratio = 3.52 [1.17-10.62]; P = 0.025).

CONCLUSIONS

The combination of R-EBUS with TBB resulted in a higher diagnostic yield than either technique alone. Thus, the addition of R-EBUS biopsy would be helpful to improve the diagnostic yield of TBB.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: The combination of R-EBUS with TBB under fluoroscopic guidance improved the diagnostic yield of PPLs compared to TBB alone. A tissue diagnosis was more likely in pulmonary lesions with the air-bronchus sign.

WHAT THIS STUDY ADDS

The use of R-EBUS could help improve the low diagnostic yield of TBB under fluoroscopic guidance without increasing the incidence of complications.

Virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy

Guided bronchoscopy offers a minimally invasive and safe method for accessing indeterminate pulmonary nodules. However, all current guided bronchoscopy systems rely on a preprocedural computed tomography (CT) scan to create a virtual map of the patient's airways. Changes in lung anatomy between the preprocedural CT scan and the bronchoscopy procedure can lead to a divergence between the expected and actual location of the target lesion. Termed "CT-to-body divergence", this effect reduces diagnostic yield, adds time to the procedure, and can be challenging for the operator. The objective of this paper is to describe the concept of CT-to-body divergence, its contributing factors, and methods and technologies that might minimize its deleterious effects on diagnostic yield.

Technologies for targeting the peripheral pulmonary nodule including robotics

Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground-glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes.

An Evaluation of Diagnostic Yield From Bronchoscopy: The Impact of Clinical/Radiographic Factors, Procedure Type, and Degree of Suspicion for Cancer

BACKGROUND

Bronchoscopy is commonly used to evaluate suspicious lung lesions. The yield is likely dependent on patient, radiographic, and bronchoscopic factors. Few studies have assessed these factors simultaneously while also including the preprocedure physician-assessed probability of cancer (pCA) when assessing yield.

METHODS

This study is a secondary data analysis from a prospective multicenter trial. Diagnostic yield of standard bronchoscopy with biopsy ± fluoroscopy, endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), electromagnetic navigation, and combination bronchoscopies was assessed. Definitions for diagnostic and nondiagnostic bronchoscopies were rigorously predefined. The association of diagnostic yield with individual variables was examined by using univariate and multivariate logistic regression analyses where appropriate.

RESULTS

A total of 687 patients were included from 28 sites. Overall diagnostic yield was 69%; 80% for EBUS, 55% for bronchoscopy with biopsy ± fluoroscopy, 57% for electromagnetic navigation, and 74% for combination procedures (P < .001). Patients with larger, central lesions with adenopathy were significantly more likely to undergo a diagnostic bronchoscopy. Patients with pCA < 10% and 10% to 60% had lower yields (44% and 42%, respectively), whereas pCA > 60% yielded a positive result in 77% (P < .001). In multivariate logistic regression, the use of EBUS-TBNA, larger sized lesions, and central location were significantly associated with a diagnostic bronchoscopy. Seventeen percent of those with a malignant diagnosis and 28% of those with a benign diagnosis required secondary procedures to establish a diagnosis.

CONCLUSIONS

This study is the first to assess the yield of bronchoscopy according to physician-assessed pCA in a large, prospective multicenter trial. The yield of bronchoscopy varied greatly according to physician suspicion that cancer is present, the patients' clinical/radiographic features, and the type of procedure performed. Of the procedures performed, EBUS-TBNA was the most likely to provide a diagnosis.

Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience

Background

The Robotic Endoscopic System (Auris Health, Inc., Redwood City, CA) has the potential to overcome several limitations of contemporary guided-bronchoscopic technologies for the diagnosis of lung lesions. Our objective is to report on the initial post-marketing feasibility, safety and diagnostic yield of this technology.

Methods

We retrospectively reviewed data on consecutive cases in which robot-assisted bronchoscopy was used to sample lung lesions at four centers in the US (academic and community) from June 15th, 2018 to December 15th, 2018.

Results

One hundred and sixty-seven lesions in 165 patients were included in the analysis, with an average follow-up of 185 ± 55 days. The average size of target lesions was 25.0 ± 15.0 mm. Seventy-one percent were located in the peripheral third of the lung. Pneumothorax and airway bleeding occurred in 3.6 and 2.4% cases, respectively. Navigation was successful in 88.6% of cases. Tissue samples were successfully obtained in 98.8%. The diagnostic yield estimates ranged from 69.1 to 77% assuming the cases of biopsy-proven inflammation without any follow-up information (N = 13) were non-diagnostic and diagnostic, respectively. The yield was 81.5, 71.7 and 26.9% for concentric, eccentric and absent r-EBUS views, respectively. Diagnostic yield was not affected by lesion size, density, lobar location or centrality.

Conclusions

RAB implementation in community and academic centers is safe and feasible, with an initial diagnostic yield of 69.1–77% in patients with lung lesions that require diagnostic bronchoscopy. Comparative trials with the existing bronchoscopic technologies are needed to determine cost-effectiveness of this technology.

Accuracy of a Robotic Endoscopic System in Cadaver Models with Simulated Tumor Targets: ACCESS Study

BACKGROUND

Bronchoscopy for the diagnosis of peripheral pulmonary lesions continues to present clinical challenges, despite increasing experience using newer guided techniques. Robotic bronchoscopic platforms have been developed to potentially improve diagnostic yields. Previous studies in cadaver models have demonstrated increased reach into the lung periphery using robotic systems compared to similarly sized conventional bronchoscopes, although the clinical impact of additional reach is unclear.

OBJECTIVES

This study was performed to evaluate the performance of a robotic bronchoscopic system's ability to reach and access artificial tumor targets simulating peripheral nodules in human cadaveric lungs.

METHODS

Artificial tumor targets sized 10-30 mm in axial diameter were implanted into 8 human cadavers. CT scans were performed prior to procedures and all cadavers were intubated and mechanically ventilated. Electromagnetic navigation, radial probe endobronchial ultrasound, and fluoroscopy were used for all procedures. Robotic-assisted bronchoscopy was performed on each cadaver by an individual bronchoscopist to localize and biopsy peripheral lesions.

RESULTS

Sixty-seven nodules were evaluated in 8 cadavers. The mean nodule size was 20.4 mm. The overall diagnostic yield was 65/67 (97%) and there was no statistical difference in diagnostic yield for lesions <20 mm compared with lesions measuring 21-30 mm, the presence of a concentric or eccentric radial ultrasound image, or relative distance from the pleura.

CONCLUSIONS

The robotic bronchoscopic system was successful at biopsying 97% of peripheral pulmonary lesions 10-30 mm in size in human cadavers. These findings support further exploration of this technology in prospective clinical trials in live human subjects.

First-in-Human Use of a Hybrid Real-Time Ultrasound-Guided Fine-Needle Acquisition System for Peripheral Pulmonary Lesions: A Multicenter Pilot Study

BACKGROUND

The ability to successfully perform a biopsy on pulmonary lesions by means of bronchoscopy varies widely due to anatomic and technological limitations. One major limitation is the lack of the ability to utilize real-time guidance during tissue sampling in the periphery. A novel system has been developed that enables real-time visualization and sampling of peripheral lesions by displaying an ultrasound image of the lesion and needle simultaneously.

METHODS

We performed a multicenter, prospective pilot in patients with peripheral pulmonary lesions undergoing a clinically indicated bronchoscopy. The purpose of this study was to demonstrate the feasibility of visualizing, accessing, and obtaining specimens adequate for the cytology of lung lesions when using a novel hybrid real-time ultrasound-guided fine-needle aspiration system for peripheral pulmonary lesions.

RESULTS

Twenty-three patients underwent bronchoscopic sampling of a peripheral pulmonary lesion with the study device. Mean lesion size was 3.6 (range 1.7-5.7) cm. Targeted lesions were located in all lobes of the lung. All lesions were successfully visualized and sampled under real-time visualization with specimens adequate for cytological evaluation. The needle was visualized in all lesions throughout targeting and sampling. There were no incidents of pneumothorax or moderate-to-severe bleeding.

CONCLUSION

In this feasibility study, we report the first-in-human use of a continuous real-time endobronchial ultrasound guidance system to sample peripheral pulmonary lesions. Future generations of this device may improve usability and further studies are needed to determine the true diagnostic capabilities of this novel technique.

A Prospective Randomized Comparative Study of Three Guided Bronchoscopic Approaches for Investigating Pulmonary Nodules: The PRECISION-1 Study

BACKGROUND

The capability of bronchoscopy in the diagnosis of peripheral pulmonary nodules (PPNs) remains limited. Despite decades of effort, evidence suggests that the diagnostic accuracy for electromagnetic navigational bronchoscopy (EMN) and radial endobronchial ultrasound (EBUS) approach only 50%. New developments in robotic bronchoscopy (RB) may offer improvements in the assessment of PPNs.

METHODS

A prospective single-blinded randomized controlled comparative study to assess success in localization and puncture of PPNs, using an ultrathin bronchoscope with radial EBUS (UTB-rEBUS) vs EMN vs RB in a human cadaver model of PPNs < 2 cm, was performed. The primary end point was the ability to successfully localize and puncture the target nodule, verified by cone-beam CT comparing RB and EMN. Secondary end points included needle to target position "miss" distance, and UTB-rEBUS comparisons.

RESULTS

Sixty procedures were performed to target 20 PPNs over the study period. Implanted PPNs were distributed across all lobes, with 80% located within the lung periphery. The target PPN mean diameter was 16.5 ± 1.5 mm, with 50% noted to have a CT bronchus sign. The rate of successful PPN localization and puncture was superior when using RB, compared with EMN (80% vs 45%; P = .02). Among unsuccessful needle passes, the median needle to target "miss" distance was significantly different when comparing UTB-rEBUS, EMN, and RB (P = .0014).

CONCLUSIONS

In a cadaver model, use of RB significantly increased the ability to localize and successfully puncture small PPNs when compared with existing technologies. This study demonstrates the potential of RB to precisely reach, localize, and puncture small nodules in the periphery of the lung.

Use of an Ultrathin vs Thin Bronchoscope for Peripheral Pulmonary Lesions: A Randomized Trial

BACKGROUND

When evaluating peripheral pulmonary lesions, a 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel is advantageous regarding good access to the peripheral airway, whereas a 4.0-mm thin bronchoscope provides a larger 2.0-mm working channel, which allows the use of various instruments including a guide sheath (GS), larger forceps, and an aspiration needle. This study compared multimodal bronchoscopy using a UTB and a thin bronchoscope with multiple sampling methods for the diagnosis of peripheral pulmonary lesions.

METHODS

Patients with peripheral pulmonary lesions ≤ 30 mm in diameter were recruited and randomized to undergo endobronchial ultrasonography, virtual bronchoscopy, and fluoroscopy-guided bronchoscopy using a 3.0-mm UTB (UTB group) or a 4.0-mm thin bronchoscope (thin bronchoscope group). In the thin bronchoscope group, the use of small forceps with a GS or standard forceps without the GS was permitted. In addition, needle aspiration was performed for lesions into which an ultrasound probe could not be inserted.

RESULTS

A total of 360 patients were enrolled, and 356 were included in the analyses (median largest lesional diameter, 19 mm). The overall diagnostic yield was significantly higher in the UTB group than in the thin bronchoscope group (70.1% vs 58.7%, respectively; P = .027). The procedure duration was significantly shorter in the UTB group (median, 24.8 vs 26.8 min, respectively; P = .008). The complication rates were 2.8% and 4.5%, respectively (P = .574).

CONCLUSIONS

Multimodal bronchoscopy using a UTB afforded a higher diagnostic yield than that using a thin bronchoscope in the diagnosis of small peripheral pulmonary lesions.

TRIAL REGISTRY

UMIN Clinical Trials Registry; No.: UMIN000010133; URL: https://www.umin.ac.jp/ctr/.

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Introduction: The incidence of peripheral pulmonary lesions (PPLs) is growing following the adoption of lung cancer screening by low-dose chest CT. Although CT-guided transthoracic needle aspiration has been the standard method to diagnose PPLs, the field of interventional bronchoscopy is rapidly advancing to overcome complications of the transthoracic approach yet maintain the yield. Areas covered: This article reviews the clinical evidence of recent emerging interventional bronchoscopic techniques for diagnosis of PPLs. Expert opinion: Recent advances in interventional bronchoscopy contribute to not only the safety of transbronchial approaches to PPLs but also the higher diagnostic yield. To perform accurate sampling of PPLs, bronchoscopists must select the correct airway, approach the target as close as possible, and confirm the location of the target before sampling. These key steps can be assisted by recently developed technologies. However, it is important for bronchoscopists to understand the strengths and limitations of these emerging technologies.

Improved diagnostic yield for lung nodules with digital tomosynthesis-corrected navigational bronchoscopy: Initial experience with a novel adjunct

BACKGROUND AND OBJECTIVE

The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is inferior to that of computed tomography (CT)-guided needle biopsy for pulmonary nodules. One explanation for this is divergence between the nodule location on the pre-procedure CT scan and its actual location during the procedure. Fluoroscopic ENB (F-ENB) consists of digital tomosynthesis using a conventional C-arm to re-register the target lesion based on near real-time imaging. We performed a retrospective review of ENB cases at our institution before and after introduction of F-ENB to assess diagnostic yield.

METHODS

All consecutive ENB procedures performed at our institution from 25 December 2017 to 25 August 2018 were reviewed. F-ENB was introduced on 25 April 2018. Two cohorts were analysed: standard ENB (S-ENB) from 25 December 2017 to 24 April 2018 and F-ENB from 25 April 2018 to 25 August 2018. All procedural, demographic and diagnostic data were collected. Descriptive statistics, chi-square, Wilcoxon test and Student's t-test were used where appropriate. A multivariable regression analysis was performed to assess factors associated with diagnostic yield.

RESULTS

A total of 101 and 67 nodules were biopsied in the S-ENB and F-ENB groups, respectively. Diagnostic yield was 54% in S-ENB cohort and 79% in the F-ENB group (P = 0.0019). Factors independently associated with a positive diagnosis were F-ENB and a positive radial ultrasound view (odds ratio (OR): 3.57, 95% CI: 1.56-8.18 and OR: 3.74, 95% CI: 1.37-11.05, respectively). Complications were minimal (pneumothorax: 1.5%).

CONCLUSION

The use of F-ENB may increase the diagnostic yield of ENB and has a low complication rate.

Robotic assisted-bronchoscopy: technical tips and lessons learned from the initial experience with sampling peripheral lung lesions

Background

Peripheral pulmonary nodules are increasingly detected in patients screened for lung cancer or during disease progression of thoracic or extrathoracic malignancies. Sampling these lesions requires surgery, computed tomography (CT)-guided biopsy or bronchoscopic interventions. Bronchoscopic interventions are preferable because they have lower complications and often patients may not be ideal candidates for surgical or CT-guided biopsy. In addition, guidelines recommend diagnosis and staging in one single procedure. The diagnostic yield of existing advanced bronchoscopic techniques including electromagnetic navigation, radial probe ultrasonography, ultrathin bronchoscopy or virtual bronchoscopy remains suboptimal. The purpose of this paper is to codify the technique whereby a diagnostic bronchoscopy is performed using the new robotic platform.

Methods

In the present report, I describe the technique for performing robotic-assisted bronchoscopy (RAB) using the Monarch™ platform (Auris Health, Inc., Redwood City, CA).

Results

Appropriate team training, patient selection, anesthesia settings, optimal tissue acquisition and processing, and prevention of complications are described and illustrated.

Conclusions

RAB may be beneficial for patients with peripheral lung lesions that require biopsy prior to surgical resection, stereotactic radiation, targeted or immunotherapy.

Transbronchial evaluation of peripheral pulmonary lesions using ultrasonic spectrum analysis in lung cancer patients

BACKGROUND AND OBJECTIVE

Analysis of the endobronchial ultrasound (EBUS) radiofrequency spectrum has been used for convex-probe EBUS technology. Quantitative imaging analysis is also warranted for guided bronchoscopy using radial-probe EBUS (RP-EBUS) targeting peripheral pulmonary lesions (PPL). This study aimed to determine the feasibility of radiofrequency spectrum analysis for distinguishing malignant and benign PPL during diagnostic bronchoscopy.

METHODS

Raw RP-EBUS images with radiofrequency data, including backscatter signals, were prospectively recorded. The ultrasonic spectral parameters, such as intercept, midband-fit and slope within the region of interest, were retrospectively computed by linear regression analysis and compared with the final diagnosis.

RESULTS

A total of 71 PPL, including 45 malignant and 26 benign lesions, were analysed. Malignant PPL showed a significantly lower intercept (P < 0.0001), lower midband-fit (P < 0.0001) and higher slope (P = 0.014) than benign PPL. Analyses of the area under the curve of receiver operating characteristic plots demonstrated that the intercept showed the best diagnostic performance among three parameters (0.87, 0.77 and 0.69 for intercept, midband-fit and slope, respectively). The sensitivity, specificity, accuracy, positive likelihood and negative likelihood were 75.6%, 96.2%, 83.1%, 19.6 and 0.25 for the intercept; 88.9%, 57.7%, 77.5%, 2.1 and 0.19 for the midband-fit; and 68.9%, 73.1%, 70.4%, 2.6 and 0.43 for the slope.

CONCLUSION

Spectrum analysis of EBUS radiofrequency can be used as a novel non-invasive predictor of malignant or benign PPL. Analysis of the 'intercept' of the targeted lesion may provide useful supporting data for real-time sampling from PPL during diagnostic bronchoscopy.

Cone beam computed tomography-guided thin/ultrathin bronchoscopy for diagnosis of peripheral lung nodules: a prospective pilot study

Background

Despite advances in bronchoscopy, its diagnostic yield for peripheral lung lesions continues to be suboptimal. Cone beam computed tomography (CBCT) could be utilized to corroborate the accuracy of our bronchoscopic navigation and hopefully increase its diagnostic yield. However, data on radiation exposure and feasibility of CBCT-guided bronchoscopy is scarce.

Methods

Prospective pilot study of bronchoscopy for peripheral lung nodules under general anesthesia with thin/ultrathin bronchoscope, radial-probe endobronchial ultrasound (RP-EBUS), and CBCT. Main objective was to estimate radiation dose and secondary objective was the additional value of CBCT in terms of navigational and diagnostic yield.

Results

A total of 20 patients were enrolled. Median lesion size was 2.1 (range, 1.1-3) cm and distance from pleura was 2.1 (range, 0-2.8) cm. "Bronchus sign" was present in 12 (60%) of the lesions. Totally, 12 lesions (60%) were invisible on fluoroscopy. CBCT identified atelectasis obscuring the target in 4 cases (20%). Eleven patients (55%) underwent 1 CBCT scan and 9 patients (45%) 2. The mean estimated effective dose (E) to patients resulting from CBCT ranged between 8.6 and 23 mSv, depending on utilized conversion factors. Both pre-CBCT navigation and diagnostic yield were 50%. Additional post-CBCT maneuvers increased navigation yield to 75% (P=0.02) and diagnostic yield to 70% (P=0.04). One patient developed a pneumothorax.

Conclusions

CBCT-guided bronchoscopy is associated with an acceptable radiation dose. CBCT may potentially increase both navigation and diagnostic yield of thin/ultrathin bronchoscopy for peripheral lung nodules. The above findings as well as the incidental but relevant finding of intra-procedural atelectasis need to be confirmed in larger prospective studies.

Trial registration

This study is registered in ClinicalTrials.gov as number NCT02978170.