Electromagnetic Navigation Bronchoscopy: Where Are We Now? Five Years of a Single-Center Experience

Guided Bronchoscopy for the Evaluation of Pulmonary Lesions: An Updated Meta-analysis

BACKGROUND

Guided bronchoscopy is increasingly used to diagnose peripheral pulmonary lesions (PPLs). A meta-analysis published in 2012 demonstrated a pooled diagnostic yield of 70%; however, recent publications have documented yields as low as 40% and as high as 90%.

RESEARCH QUESTION

Has the diagnostic yield of guided bronchoscopy in patients with PPLs improved over the past decade?

STUDY DESIGN AND METHODS

A comprehensive search was performed of studies evaluating the diagnostic yield of differing bronchoscopic technologies used to reach PPLs. Study quality was assessed using the Quality assessment of diagnostic accuracy of studies (QUADAS-2) assessment tool. Number of lesions, type of technology used, overall diagnostic yield, and yield by size were extracted. Adverse events were recorded. Meta-analytic techniques were used to summarize findings across all studies.

RESULTS

A total of 16,389 lesions from 126 studies were included. There was no significant difference in diagnostic yield prior to 2012 (39 studies; 3,052 lesions; yield 70.5%) vs after 2012 (87 studies; 13,535 lesions; yield 69.2%) (P > .05). Additionally, there was no significant difference in yield when comparing different technologies. Studies with low risk of overall bias had a lower diagnostic yield than those with high risk of bias (66% vs 71%, respectively; P = .018). Lesion size > 2 cm, presence of bronchus sign, and reports with a high prevalence of malignancy in the study population were associated with significantly higher diagnostic yield. Significant (P < .0001) between-study heterogeneity was also noted.

INTERPRETATION

Despite the reported advances in bronchoscopic technology to diagnose PPLs, the diagnostic yield of guided bronchoscopy has not improved.

Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis

BACKGROUND

Navigation bronchoscopy has seen rapid development in the past decade in terms of new navigation techniques and multi-modality approaches utilizing different techniques and tools. This systematic review analyses the diagnostic yield and safety of navigation bronchoscopy for the diagnosis of peripheral pulmonary nodules suspected of lung cancer.

METHODS

An extensive search was performed in Embase, Medline and Cochrane CENTRAL in May 2022. Eligible studies used cone-beam CT-guided navigation (CBCT), electromagnetic navigation (EMN), robotic navigation (RB) or virtual bronchoscopy (VB) as the primary navigation technique. Primary outcomes were diagnostic yield and adverse events. Quality of studies was assessed using QUADAS-2. Random effects meta-analysis was performed, with subgroup analyses for different navigation techniques, newer versus older techniques, nodule size, publication year, and strictness of diagnostic yield definition. Explorative analyses of subgroups reported by studies was performed for nodule size and bronchus sign.

RESULTS

A total of 95 studies (n = 10,381 patients; n = 10,682 nodules) were included. The majority (n = 63; 66.3%) had high risk of bias or applicability concerns in at least one QUADAS-2 domain. Summary diagnostic yield was 70.9% (95%-CI 68.4%-73.2%). Overall pneumothorax rate was 2.5%. Newer navigation techniques using advanced imaging and/or robotics(CBCT, RB, tomosynthesis guided EMN; n = 24 studies) had a statistically significant higher diagnostic yield compared to longer established techniques (EMN, VB; n = 82 studies): 77.5% (95%-CI 74.7%-80.1%) vs 68.8% (95%-CI 65.9%-71.6%) (p < 0.001).Explorative subgroup analyses showed that larger nodule size and bronchus sign presence were associated with a statistically significant higher diagnostic yield. Other subgroup analyses showed no significant differences.

CONCLUSION

Navigation bronchoscopy is a safe procedure, with the potential for high diagnostic yield, in particular using newer techniques such as RB, CBCT and tomosynthesis-guided EMN. Studies showed a large amount of heterogeneity, making comparisons difficult. Standardized definitions for outcomes with relevant clinical context will improve future comparability.

Non‑diagnostic electromagnetic navigation bronchoscopy biopsy: Predictive factors and final diagnoses

The present study aimed to explore the final diagnosis of pulmonary nodules with an initial non-diagnostic result on electromagnetic navigation bronchoscopy (ENB) biopsy and the predictive factors for a non-diagnostic result. A total of 198 nodules from 194 patients that were suspected to be malignant tumors were included in the present study. The initial biopsy pathology results were divided into two groups: The diagnostic group and the non-diagnostic group. The diagnostic group was defined as a successful initial biopsy to obtain a diagnosis, including malignant and benign diagnoses. The non-diagnostic group was defined as a non-specific benign diagnosis, normal lung tissue or an unsuccessful biopsy. Among the 198 nodules, 139 (70.2%) were in the diagnostic group and 59 (29.8%) were in the non-diagnostic group. Predictive factors for a non-diagnostic biopsy included nodule size ≤1.5 cm [odds ratio (OR), 2.05; 95% confidence interval (CI), 1.03-4.09], non-solid nodules (OR, 2.71; 95% CI, 1.33-5.64) and nodules in the left lung (OR, 2.50; 95% CI, 1.27-4.92). Of the 59 non-diagnostic biopsies, 46 were finally confirmed to be malignant by surgery. Notably, non-diagnostic biopsies with non-solid nodules (OR, 7.64; 95% CI, 3.11-18.76) were more likely to be malignant. In conclusion, the predictive factors for a non-diagnostic biopsy were nodule size ≤1.5 cm and non-solid nodules. It was not rare for patients to finally be diagnosed with a malignancy in the non-diagnostic group. Therefore, care should be taken when the results of an ENB are non-diagnostic to prevent misdiagnosis.

Current investigative modalities for detecting and staging lung cancers: a comprehensive summary

This narrative review compares the advantages and drawbacks of imaging and other investigation modalities which currently assist with lung cancer diagnosis and staging, as well as those which are not routinely indicated for this. We examine plain film radiography, computed tomography (CT) (alone, as well as in conjunction with positron emission tomography (PET)), magnetic resonance imaging (MRI), ultrasound, and newer techniques such as image-guided bronchoscopy (IGB) and robotic bronchoscopy (RB). While a chest X-ray is the first-line imaging investigation in patients presenting with symptoms suggestive of lung cancer, it has a high positive predictive value (PPV) even after negative X-ray findings, which calls into question its value as part of a potential national screening programme. CT lowers the mortality for high-risk patients when compared to X-ray and certain scoring systems, such as the Brock model can guide the need for further imaging, like PET-CT, which has high sensitivity and specificity for diagnosing solitary pulmonary nodules as malignant, as well as for assessing small cell lung cancer spread. In practice, PET-CT is offered to everyone whose lung cancer is to be treated with a curative intent. In contrast, MRI is only recommended for isolated distant metastases. Similarly, ultrasound imaging is not used for diagnosis of lung cancer but can be useful when there is suspicion of intrathoracic lymph node involvement. Ultrasound imaging in the form of endobronchial ultrasonography (EBUS) is often used to aid tissue sampling, yet the diagnostic value of this technique varies widely between studies. RB is another novel technique that offers an alternative way to biopsy lesions, but further research on it is necessary. Lastly, thoracic surgical biopsies, particularly minimally invasive video-assisted techniques, have been used increasingly to aid in diagnosis and staging.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

4D Electromagnetic Navigation Bronchoscopy for the Sampling of Pulmonary Lesions: First European Real-Life Experience

Purpose

The use of Electromagnetic navigation bronchoscopy (ENB) for the diagnosis of pulmonary peripheral lesions is still debated due to its variable diagnostic yield; a new 4D ENB system, acquiring inspiratory and expiratory computed tomography (CT) scans, overcomes respiratory motion and uses tracked sampling instruments, reaching higher diagnostic yields. We aimed at evaluating diagnostic yield and accuracy of a 4D ENB system in sampling pulmonary lesions and at describing their influencing factors.

Methods

We conducted a three-year retrospective observational study including all patients with pulmonary lesions who underwent 4D ENB with diagnostic purposes; all the factors potentially influencing diagnosis were recorded.

Results

103 ENB procedures were included; diagnostic yield and accuracy were, respectively, 55.3% and 66.3%. We reported a navigation success rate of 80.6% and a diagnosis with ENB was achieved in 68.3% of cases; sensitivity for malignancy was 61.8%. The majority of lesions had a bronchus sign on CT, but only the size of lesions influenced ENB diagnosis (p < 0.05). Transbronchial needle aspiration biopsy was the most used tool (93.2% of times) with the higher diagnostic rate (70.2%). We reported only one case of pneumothorax.

Conclusion

The diagnostic performance of a 4D ENB system is lower than other previous navigation systems used in research settings. Several factors still influence the reachability of the lesion and therefore diagnostic yield. Patient selection, as well as the multimodality approach of the lesion, is strongly recommended to obtain higher diagnostic yield and accuracy, with a low rate of complications.

Diagnostic Performance of Electromagnetic Navigation Bronchoscopy-Guided Biopsy for Lung Nodules in the Era of Molecular Testing

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

The Impact of Biopsy Tool Choice and Rapid On-Site Evaluation on Diagnostic Accuracy for Malignant Lesions in the Prospective: Multicenter NAVIGATE Study

BACKGROUND

The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is impacted by biopsy tool strategy and rapid on-site evaluation (ROSE) use. This analysis evaluates usage patterns, accuracy, and safety of tool strategy and ROSE in a multicenter study.

METHODS

NAVIGATE (NCT02410837) evaluates ENB using the superDimension navigation system (versions 6.3 to 7.1). The 1-year analysis included 1215 prospectively enrolled subjects at 29 United States sites. Included herein are 416 subjects who underwent ENB-aided biopsy of a single lung lesion positive for malignancy at 1 year. Use of a restricted number of tools (only biopsy forceps, standard cytology brush, and/or bronchoalveolar lavage) was compared with an extensive multimodal strategy (biopsy forceps, cytology brush, aspirating needle, triple needle cytology brush, needle-tipped cytology brush, core biopsy system, and bronchoalveolar lavage).

RESULTS

Of malignant cases, 86.8% (361/416) of true positive diagnoses were obtained using extensive multimodal strategies. ROSE was used in 300/416 cases. The finding of malignancy by ROSE reduced the total number of tools used. A malignant ROSE call was obtained in 71% (212/300), most (88.7%; 188/212) by the first tool used (49.5% with aspirating needle, 20.2% with cytology brush, 17.0% with forceps). True positive rates were highest for the biopsy forceps (86.9%) and aspirating needle (86.6%). Use of extensive tool strategies did not increase the rates of pneumothorax (5.5% restricted, 2.8% extensive) or bronchopulmonary hemorrhage (3.6% restricted, 1.1% extensive).

CONCLUSION

These results suggest that extensive biopsy tool strategies, including the aspirating needle, may provide higher true positive rates for detecting lung cancer without increasing complications.

Diagnostic yield and safety of biopsy guided by electromagnetic navigation bronchoscopy for high-risk pulmonary nodules

Background

Electromagnetic navigation bronchoscopy (ENB) is a useful method to obtain tissue for peripheral lung nodules. We aimed to understand the diagnostic yield and safety profile in high‐risk pulmonary nodules that cannot be accessed by percutaneous transthoracic needle biopsy.

Methods

In this single‐center retrospective study, we reviewed patients who underwent ENB for high‐risk pulmonary nodules. All procedures were performed under moderate sedation using intravenous midazolam and fentanyl.

Results

A total of 100 pulmonary nodules in 90 patients were subjected to ENB between October 2018 and May 2020. The median age of the study population was 66 (59–73). The mean diameter of the lung nodules was 27.9 mm. The diagnostic yield of ENB‐guided biopsy was 53.0%. Although the nodule size (odds ratio: 1.055, p = 0.007) and positive bronchus sign (odds ratio: 2.918, p = 0.020) were associated with the diagnostic yield during univariate analysis, nodule size was the only independent variable on the multivariable analysis. Interestingly, the diagnostic yield showed an upward trend after 60 cases, from 45%–65%. Procedure‐related complications were reported in 16 cases; among these, pneumothorax occurred in three cases, and four cases experienced moderate bleeding. No instance of major bleeding or death was linked to ENB‐guided biopsy.

Conclusion

ENB‐guided biopsy for high‐risk pulmonary nodules demonstrated an acceptable diagnostic yield and good safety profile. Moreover, the diagnostic yield was associated with nodule size and procedure experience.

Lesion characteristics affecting yield of electromagnetic navigational bronchoscopy

RATIONALE

Electromagnetic navigational bronchoscopy (ENB) is an important, minimally invasive diagnostic tool for malignant and benign peripheral lung lesions, offering lower complication risks than transthoracic needle aspirations. As a relatively new technology, the best sampling modality and lesion characteristics for ENB has yet to be determined. We evaluated the sensitivity and diagnostic yield of different sampling modalities (needle aspiration, brush biopsy, transbronchial forceps biopsies) and radiographical lesion characteristics by Tsuboi classification. We also evaluated the difference in yield and sensitivity with the addition of radial probe EBUS to augment ENB.

METHODS

We completed a retrospective chart review of all patients that had ENB performed at our institution since its implementation in 2011. We reviewed the lesion size, location, Tsuboi classification, cytology, pathology results and analyzed biopsy specimen tool types.

RESULTS

We included a total of 248 patients who had ENB performed between 2011 and 2018. Average age was 67 years and 50% female. A total of 270 lesions were targeted with a mean size of 24 ± 12 mm. Sensitivity for malignancy was 59.2% with a diagnostic yield of 72.3%. Sensitivity and diagnostic accuracy trended higher with combined sampling modalities (brush and transbronchial needle aspiration and forcep biopsy). Lesions with type I and type II Tsuboi classification of bronchus sign had higher sensitivity compared to type III classification (67.9% [n = 101 type I], 64.6% [n = 65 type II], 37.9% [n = 36 type III]), p = 0.01 and p = 0.04.

CONCLUSION

For navigation bronchoscopy, sensitivity is higher in bronchus sign lesions that end directly into lesion (Tsuboi type I) and travel through malignant lesions (Tsuboi type II) compared to tangentially circumventing the lesion (Tsuboi type III).

[Current Status and Development of Interventional Techniques for Pulmonary Diseases]

Bronchoscope is the core part of the interventional diagnosis and treatment technology for lung diseases, which has experienced more than 100 years of development history. It has gradually formed a diagnosis and treatment model of pulmonary diseases with cooperation of multi-clinical disciplines, deep integration of interventional minimally invasive techniques, and cross-integration of diversified diagnosis and treatment concepts. This article aimed to review the current status and development of interventional diagnosis and treatment techniques for lung diseases, and introduces the characteristics of the interventional treatment of our center.

Comparative analysis of programmed death ligand 1 expression in paired cytologic and histologic specimens of non-small cell lung cancer

BACKGROUND

In advanced non-small cell lung cancer (NSCLC), cytologic specimens from transbronchial needle aspiration (TBNA) or transthoracic needle aspiration are often the only cancer tissue material available for the analysis of programmed death ligand 1 (PD-L1) expression. This study was aimed at assessing the concordance of PD-L1 expression in histologic and cytologic samples and at evaluating interobserver agreement on specimens in this setting.

METHODS

One hundred and thirty-eight specimens from 60 patients with NSCLC were analyzed. Histologic specimens were represented by endoscopic samples obtained with forceps (biopsies), whereas cytologic specimens were from TBNA and bronchial lavage (BL). PD-L1 expression was quantified with the immunohistochemistry (IHC)-based Ventana SP263 assay. For cytologic specimens, IHC was performed on cell block sections. Two independent pathologists who were blinded to the clinical data evaluated partial or complete membrane IHC staining. Concordance between 2 methods and between 2 pathologists was evaluated with normal and weighted Cohen's κ coefficients, overall agreement, and Bland-Altman plots.

RESULTS

PD-L1 expression was quantified in 138 specimens from 60 patients. Concordance between cytologic and histologic approaches was moderate (κ = 0.56; weighted κ = 0.55). Also, concordance in the biopsy-TBNA and biopsy-BL subgroups was moderate (κ = 0.43 and κ = 0.47, respectively), whereas interobserver agreement was substantial (weighted κ = 0.72). A Bland-Altman plot showed an underestimation in PD-L1 values from cytologic samples in comparison with histologic ones.

CONCLUSIONS

The results demonstrate that in the absence of available histologic specimens, PD-L1 positivity in cytologic samples could be a reliable data for the oncologist to consider immune checkpoint inhibitor therapy. However, a comparison of cytologic and histologic samples has shown an underestimation of PD-L1 values in cytologic samples.

Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis

BACKGROUND

Bronchoscopy is a useful tool for the diagnosis of lesions near central airways; however, the diagnostic accuracy of these procedures for peripheral pulmonary lesions (PPLs) is a matter of ongoing debate. In this setting, electromagnetic navigation bronchoscopy (ENB) is a technique used to navigate and obtain samples from these lesions. This systematic review and meta-analysis aims to explore the sensitivity of ENB in patients with PPLs suspected of lung cancer.

RESEARCH QUESTION

In patients with peripheral pulmonary lesion suspected of lung cancer, what is the sensitivity and safety of electromagnetic navigation bronchoscopy compared to surgery or longitudinal follow up?

STUDY DESIGN AND METHODS

A comprehensive search of several databases was performed. Extracted data included sensitivity of ENB for malignancy, adequacy of the tissue sample, and complications. The study quality was assessed using the QUADAS-2 tool, and the combined data were meta-analyzed using a bivariate method model. A summary receiver operatic characteristic curve (sROC) was created. Finally, the quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Forty studies with a total of 3,342 participants were included in our analysis. ENB reported a pooled sensitivity of 77% (95% CI, 72%-82%; I² = 80.6%) and a specificity of 100% (95% CI, 99%-100%; I² = 0%) for malignancy. The sROC showed an area under the curve of 0.955 (P = .03). ENB achieved a sufficient sample for ancillary tests in 90.9% (95% CI, 84.8%-96.9%; I² = 80.7%). Risk of pneumothorax was 2.0% (95% CI, 1.0-3.0; I² = 45.2%). We found subgroup differences according to the risk of bias and the number of sampling techniques. Meta-regression showed an association between sensitivity and the mean distance of the sensor tip to the center of the nodule, the number of tissue sampling techniques, and the cancer prevalence in the study.

INTERPRETATION

ENB is very safe with good sensitivity for diagnosing malignancy in patients with PPLs. The applicability of our findings is limited because most studies were done with the superDimension navigation system and heterogeneity was high.

TRIAL REGISTRY

PROSPERO; No.: CRD42019109449; URL: https://www.crd.york.ac.uk/prospero/.

[Minimally Invasive Therapies for Early Stage Non-small Cell Lung Cancer]

肺癌是目前全球最常见的癌症和癌症死亡的主要原因，其中非小细胞肺癌（non-small-cell lung cancer, NSCLC）约占肺癌总数的85%。随着计算机断层扫描（computed tomography, CT）等影像学筛查手段得到不断普及，肺癌的病理类型从以往以晚期中央型肺鳞癌为主，转变为现在的以早期周围型磨玻璃样结节等为表现的肺腺癌为主。肺癌的早诊早治有着重要意义，而微创介入技术的不断发展完善，使得肺癌治疗有了更多的选择，例如立体定向放射、经皮穿刺消融、支气管介入等。本文将就目前临床常见的这些微创介入治疗的作用原理、优势、不足及展望做一评述。

Electromagnetic navigation bronchoscopy for lung nodule evaluation. Patient selection, diagnostic variables and safety

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) is a relatively new technique to diagnose pulmonary lesions in patients with reduced lung function. Several parameters have been shown to affect diagnostic yield including patient selection. We performed a prospective registration of data on one hundred patients who consecutively underwent electromagnetic navigation bronchoscopy. Selection criteria, patient characteristics, lesion size, distance to pleura, location of the lesion and presence of bronchus sign on computed tomography were registered.

METHODS

Navigation was performed using the superDimension hardware and software system. Patients were referred to ENB from a multidisciplinary team conference. We did not use fluoroscopy, endobronchial ultrasound equipment, rapid onsite evaluation or general anesthesia during the procedure. All patients in whom no malignant diagnose was found were subsequently followed for two years in order to verify a benign nature of the pulmonary lesion.

RESULTS

One hundred and nine ENB procedures were performed between September 2009 and November 2014. Overall diagnostic yield was 68%. Twenty seven of 49 malignant tumors were found by ENB leading to a sensitivity for malignancy of 55%. The sensitivity for malignancy was significantly higher for lesions in the upper and middle lobes compared to the lower lobes (P = 0.01). Lesions size, distance to pleura and presence of bronchus sign did not affect sensitivity.

CONCLUSION

ENB is a safe diagnostic procedure in an everyday setting with an acceptable diagnostic yield even without addition of supportive diagnostic methods and offers a possibility to diagnose pulmonary nodules in patients for whom other diagnostic procedures are too hazardous or have proven unsuccessful.

Interferon signature in immunosuppressed patients with lower respiratory tract infections: dosage on bronchoalveolar lavage

BACKGROUND

Interferon signature (IS) is the measure of transcripts belonging to pathways of interferon activation. Viral infections can interfere with the interferon pathway, in particular herpesvirus present in immunocompromised hosts. The aim of our study was to evaluate if herpesvirus infections in immunocompromised patients with lower respiratory tract infections (LRTI) could lead to IS alterations.

METHODS

We measured IS transcription of six genes on bronchoalveolar lavage of immunocompromised patients with LRTI (IFI27, IFI44, IFIT1, ISG15, RSAD2, SIGLEC1). Patients were divided in three groups based on Epstein-Barr virus (EBV) and other herpesviruses coinfections.

RESULTS

We included 56 patients, 10 without and 17 with only EBV reactivation (respectively N and E groups) and 29 with EBV and other herpesviruses (group C). IS was higher in group C (P=0.01) compared to other ones, but single gene expressions were different among groups: IFI27 was higher whereas IFIT1 and ISG15 were lower in group C (P<0.05).

CONCLUSIONS

The continuous stimulation of interferon cascade by herpesviruses enhances IS. The analysis of IS in immunocompromised population is possible by limiting the use of IFI27, IFIT1, ISG15 genes. Our preliminary results seem to indicate that IS is a useful biomarker of cellular response to herpesvirus infection in immunocompromised patients.

Navigation Bronchoscopy

With the advent of lung cancer screening, and the increasingly frequent use of computed tomography (CT) scanning for investigating non-pulmonary pathology (for example CT coronary angiogram), the number of pulmonary nodules requiring further investigation has risen significantly. Most of these nodules are found in the lung periphery, which presents challenges to biopsy, and many centers rely on trans-thoracic needle biopsy performed under image guidance by radiologists. However, the desire to minimize complications is driving the development of increasingly accurate navigation bronchoscopy platforms, something that will be crucial in the new era of bronchoscopic therapeutics for lung cancer. This review describes these platforms, summarizes the current evidence for their use, and takes a look at future developments.

Lung Cancer

Lung cancer is the world's leading cause of cancer death. Screening for lung cancer by low-dose computed tomography improves mortality. Various modalities exist for diagnosis and staging. Treatment is determined by subtype and stage of cancer; there are several personalized therapies that did not exist just a few years ago. Caring for the patient with lung cancer is a complex task. This review provides a broad outline of this disease, helping clinicians identify such patients and familiarizing them with lung cancer care options, so they are better equipped to guide their patients along this challenging journey.