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Lim JH, Shin HT, Park S, Ryu WK, Kim L, Lee KH, Ko SM, Lee SJ, Kim JS, Ryu JS. Bronchial washing fluid sequencing is useful in the diagnosis of lung cancer with necrotic tumor. Transl Oncol 2024; 50:102134. [PMID: 39353233 PMCID: PMC11472095 DOI: 10.1016/j.tranon.2024.102134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/27/2024] [Accepted: 09/19/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Early-stage lung cancers detected by low-dose computed tomography (CT) often require confirmation through invasive procedures due to the absence of endobronchial lesions. This study assesses the diagnostic utility of bronchial washing fluid (BW) sequencing, a less invasive alternative, aiming to identify patient characteristics most suited for this approach. METHODS From June 2017 to March 2018, we conducted a prospective cohort study by enrolling patients with incidental lung lesions suspected of early-stage lung cancer at two independent hospitals, and 114 were diagnosed with lung cancer while 50 were diagnosed with benign lesions. BW sequencing was performed using a targeted gene panel, and the clinical characteristics of patients detected with cancer through sequencing were identified. RESULTS Malignant cells were detected in 33 patients (28.9 %) through BW cytology. By applying specificity-focused mutation criteria, BW sequencing classified 42 patients (36.8 %) as having cancer. Among the cancer patients who were BW sequencing positive and BW cytology negative, 15 patients (75.0 %) showed necrosis on CT. The sensitivity of BW sequencing was particularly enhanced in patients with necrotic tumors, reaching 75 %. CONCLUSIONS BW sequencing presents a viable, non-invasive diagnostic option for early-stage lung cancer, especially valuable in patients with necrotic lesions. By potentially reducing the reliance on more invasive diagnostic procedures, this method could streamline clinical workflows, decrease patient burden, and improve overall diagnostic efficiency.
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Affiliation(s)
- Jun Hyeok Lim
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Hyun-Tae Shin
- Research Center for Controlling Intercellular Communication (RCIC), Inha University School of Medicine, Inha University, Incheon, South Korea; Department of Dermatology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Sunmin Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Woo Kyung Ryu
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Lucia Kim
- Department of Pathology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Kyung-Hee Lee
- Department of Radiology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Sung Min Ko
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | | | - Jung Soo Kim
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Jeong-Seon Ryu
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea.
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Kalchiem-Dekel O, Bergemann R, Ma X, Christos PJ, Miodownik D, Gao Y, Mahmood U, Adusumilli PS, Bott MJ, Dycoco J, Gelblum DY, Lee RP, Park BJ, Rocco G, Solomon SB, Jones DR, Chawla M, Husta BC. Determinants of radiation exposure during mobile cone-beam CT-guided robotic-assisted bronchoscopy. Respirology 2024; 29:803-814. [PMID: 38806394 PMCID: PMC11329349 DOI: 10.1111/resp.14765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/12/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND OBJECTIVE Robotic-assisted bronchoscopy (RAB) is an emerging modality to sample pulmonary lesions. Cone-beam computed tomography (CBCT) can be incorporated into RAB. We investigated the magnitude and predictors of patient and staff radiation exposure during mobile CBCT-guided shape-sensing RAB. METHODS Patient radiation dose was estimated by cumulative dose area product (cDAP) and cumulative reference air kerma (cRAK). Staff equivalent dose was calculated based on isokerma maps and a phantom simulation. Patient, lesion and procedure-related factors associated with higher radiation doses were identified by logistic regression models. RESULTS A total of 198 RAB cases were included in the analysis. The median patient cDAP and cRAK were 10.86 Gy cm2 (IQR: 4.62-20.84) and 76.20 mGy (IQR: 38.96-148.38), respectively. Among staff members, the bronchoscopist was exposed to the highest median equivalent dose of 1.48 μSv (IQR: 0.85-2.69). Both patient and staff radiation doses increased with the number of CBCT spins and targeted lesions (p < 0.001 for all comparisons). Patient obesity, negative bronchus sign, lesion size <2.0 cm and inadequate sampling by on-site evaluation were associated with a higher patient dose, while patient obesity and inadequate sampling by on-site evaluation were associated with a higher bronchoscopist equivalent dose. CONCLUSION The magnitude of patient and staff radiation exposure during CBCT-RAB is aligned with safety thresholds recommended by regulatory authorities. Factors associated with a higher radiation exposure during CBCT-RAB can be identified pre-operatively and solicit procedural optimization by reinforcing radiation protective measures. Future studies are needed to confirm these findings across multiple institutions and practices.
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Affiliation(s)
- Or Kalchiem-Dekel
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Reza Bergemann
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiaoyue Ma
- Division of Biostatistics and Epidemiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Weill Cornell School of Medicine, New York, NY, USA
| | - Daniel Miodownik
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yiming Gao
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Usman Mahmood
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph Dycoco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert P Lee
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gaetano Rocco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mohit Chawla
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bryan C Husta
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Liu B, Ye X, Fan W, Zhi X, Ma H, Wang J, Wang P, Wang Z, Wang H, Wang X, Niu L, Fang Y, Gu S, Lu Q, Tian H, Zhu Y, Qiao G, Zhong L, Wei Z, Zhuang Y, Liu H, Liu L, Liu L, Chi J, Sun Q, Sun J, Sun X, Yang N, Mu J, Li Y, Li C, Li C, Li X, Li K, Yang P, Yang X, Yang F, Yang W, Xiao Y, Zhang C, Zhang K, Zhang L, Zhang C, Zhang L, Zhang Y, Chen S, Chen J, Chen K, Chen W, Chen L, Chen H, Fan J, Lin Z, Lin D, Xian L, Meng Z, Zhao X, Hu J, Hu H, Liu C, Liu C, Zhong W, Yu X, Jiang G, Jiao W, Yao W, Yao F, Gu C, Xu D, Xu Q, Ling D, Tang Z, Huang Y, Huang G, Peng Z, Dong L, Jiang L, Jiang J, Cheng Z, Cheng Z, Zeng Q, Jin Y, Lei G, Liao Y, Tan Q, Zhai B, Li H. Expert consensus on the multidisciplinary diagnosis and treatment of multiple ground glass nodule-like lung cancer (2024 Edition). J Cancer Res Ther 2024; 20:1109-1123. [PMID: 39206972 DOI: 10.4103/jcrt.jcrt_563_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
ABSTRACT This expert consensus reviews current literature and provides clinical practice guidelines for the diagnosis and treatment of multiple ground glass nodule-like lung cancer. The main contents of this review include the following: ① follow-up strategies, ② differential diagnosis, ③ diagnosis and staging, ④ treatment methods, and ⑤ post-treatment follow-up.
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Affiliation(s)
- Baodong Liu
- Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Ye
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Weijun Fan
- Department of Minimally Invasive Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haitao Ma
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun Wang
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Peng Wang
- Minimally Invasive Cancer Treatment Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhongmin Wang
- Department of Interventional Radiology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongwu Wang
- Center for Respiratory Diseases, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoping Wang
- Endoscopy Center, Shandong Public Health Clinical Center, Jinan, China
| | - Lizhi Niu
- Department of Oncology, Fuda Cancer Hospital, Jinan University, Guangzhou, China
| | - Yong Fang
- Department of Medical Oncology, Sir Run Run Shaw Hospital Affiliated to the Zhejiang University School of Medicine, Hangzhou, China
| | - Shanzhi Gu
- Department of Intervention, Hunan Cancer Hospital, Changsha, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Hui Tian
- Department of Thoracic Surgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yulong Zhu
- Department of Respiratory Medicine, Xinjiang Uygur Autonomous Region Hospital of Traditional Chinese Medicine, Urumqi, China
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Lou Zhong
- Department of Thoracic Surgery, Affiliated Hospital of Nantong University, Nantong, China
| | - Zhigang Wei
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yiping Zhuang
- Department for Interventional Treatment, Jiangsu Cancer Hospital, Nanjing, China
| | - Hongxu Liu
- Department of Thoracic Surgery, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Lingxiao Liu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lei Liu
- Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiachang Chi
- Department of Interventional Oncology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qing Sun
- Department of Pathology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Jiayuan Sun
- Respiratory Endoscopy Center and Respiratory Intervention Center, Shanghai Chest Hospital, Shanghai, China
| | - Xichao Sun
- Department of Pathology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Nuo Yang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Juwei Mu
- Department of Thoracic Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuliang Li
- Department of Interventional Medicine, The Second Hospital Affiliated to Shandong University, Jinan, China
| | - Chengli Li
- Department of Imaging, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunhai Li
- Department of Radiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaoguang Li
- Minimally Invasive Treatment Center, Beijing Hospital, Beijing, China
| | - Kang'an Li
- Department of Radiology, Shanghai General Hospital, Shanghai, China
| | - Po Yang
- Department of Interventional Vascular Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xia Yang
- Department of Oncology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Fan Yang
- Department of Thoracic Surgery, Peking University People's Hospital, Beijing, China
| | - Wuwei Yang
- Department of Oncology, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yueyong Xiao
- Department of Diagnostic Radiology, Chinese PLA General Hospital, Beijing, China
| | - Chao Zhang
- Department of Oncology, Affiliated Qujing Hospital of Kunming Medical University, Qujing, China
| | - Kaixian Zhang
- Department of Oncology, Tengzhou Central People's Hospital, Tengzhou, China
| | - Lanjun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chunfang Zhang
- Department of Thoracic Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Linyou Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yi Zhang
- Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shilin Chen
- Department for Thoracic Surgery, Jiangsu Cancer Hospital, Nanjing, China
| | - Jun Chen
- Department of Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Kezhong Chen
- Department of Thoracic Surgery, Peking University People's Hospital, Beijing, China
| | - Weisheng Chen
- Department of Thoracic Surgery, Cancer Hospital Affiliated to Fujian Medical University, Fuzhou, China
| | - Liang Chen
- Department of Thoracic Surgery, Jiangsu Provincial People's Hospital, Nanjing, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jiang Fan
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai, China
| | - Zhengyu Lin
- Department of Intervention, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Dianjie Lin
- Department of Respiratory and Critical Care, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Lei Xian
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhiqiang Meng
- Minimally Invasive Cancer Treatment Center, Fudan University Shanghai Cancer Hospital, Shanghai, China
| | - Xiaojing Zhao
- Department of Thoracic Surgery, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Hu
- Department of Thoracic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongtao Hu
- Department of Minimally Invasive Interventional Therapy, Henan Cancer Hospital, Zhengzhou, China
| | - Chen Liu
- Department of Interventional Therapy, Beijing Cancer Hospital, Beijing, China
| | - Cheng Liu
- Department of Imaging, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wenzhao Zhong
- Department of Pulmonary Surgery, Guangdong Lung Cancer Institute, Guangzhou, China
| | - Xinshuang Yu
- Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Wenjie Jiao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Weirong Yao
- Department of Radiology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Feng Yao
- Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Chundong Gu
- Department of Thoracic Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dong Xu
- Department of Ultrasound Medicine, Cancer Hospital, University of Chinese Academy of Sciences, Hangzhou, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Dongjin Ling
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhe Tang
- Department of Hepatobiliary and Pancreatic Surgery, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Huang
- Department of Imaging, Cancer Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guanghui Huang
- Department of Oncology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhongmin Peng
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Liang Dong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lei Jiang
- Department of Radiology, Huadong Sanatorium, Wuxi, China
| | - Junhong Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhaoping Cheng
- Nuclear Medicine-PET Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zhigang Cheng
- Interventional Ultrasound, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qingshi Zeng
- Department of Imaging, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yong Jin
- Department of Interventional Therapy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Guangyan Lei
- Department of Thoracic Surgery, Shaanxi Provincial Cancer Hospital, Xi'an, China
| | - Yongde Liao
- Department of Thoracic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qunyou Tan
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Bo Zhai
- Department of Interventional Oncology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hailiang Li
- Department of Minimally Invasive Interventional Therapy, Henan Cancer Hospital, Zhengzhou, China
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4
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Park D. Advanced Bronchoscopic Diagnostic Techniques in Lung Cancer. Tuberc Respir Dis (Seoul) 2024; 87:282-291. [PMID: 38414369 PMCID: PMC11222101 DOI: 10.4046/trd.2023.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/28/2023] [Accepted: 02/22/2024] [Indexed: 02/29/2024] Open
Abstract
The increasing incidence of incidental pulmonary nodules necessitates effective biopsy techniques for accurate diagnosis and treatment planning. This paper reviews the widely used advanced bronchoscopic techniques, such as radial endobronchial ultrasound-guided transbronchial lung biopsy, electromagnetic navigation bronchoscopy, and the cutting-edge robotic-assisted bronchoscopy. In addition, the cryobiopsy technique, which can enhance diagnostic yield by combination with conventional biopsy tools, is described for application to peripheral pulmonary lesions and mediastinal lesions, respectively.
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Affiliation(s)
- Dongil Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
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5
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Bott MJ, Toumbacaris N, Tan KS, Husta BC, Medina BD, Adusumilli PS, Beattie JA, Lee RP, Park BJ, Dycoco J, Jones DR, Chawla M, Rocco G, Kalchiem-Dekel O. Characterizing a learning curve for robotic-assisted bronchoscopy: Analysis of skills acquisition in a high-volume academic center. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00540-3. [PMID: 38936600 DOI: 10.1016/j.jtcvs.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE Shape-sensing robotic-assisted bronchoscopy is an emerging technology for the sampling of pulmonary lesions. We seek to characterize the shape-sensing robotic-assisted bronchoscopy learning curve at an academic center. METHODS Shape-sensing robotic-assisted bronchoscopy procedures performed by 9 proceduralists at a single institution were analyzed. Cumulative sum analyses were performed to examine diagnostic sampling and procedure time over each operator's first 50 cases, with the acceptable yield threshold set to 73%. RESULTS During the study period, 442 patients underwent sampling of 551 lesions. Each operator sampled 61 lesions (interquartile range, 60-63 lesions). Lesion size was 1.90 cm (interquartile range, 1.33-2.80 cm). The median procedure time for single-target cases decreased from 62 minutes during the first 10 cases to 39 minutes after case 40 (P < .001). The overall diagnostic yield was 72% (range, 58%-83%). Six of 9 operators achieved proficiency over the study period. An aggregated cumulative sum analysis of those who achieved competency demonstrated a steep improvement between lesions 1 and 21 and crossing of the competency threshold by lesion 25. Temporal analysis of yield-related lesion characteristics demonstrated that at approximately lesion 20, more challenging lesions were increasingly targeted, as evidenced by smaller target size, higher rates of unfavorable radial endobronchial ultrasound views, and a negative bronchus sign. CONCLUSIONS Skills acquisition in shape-sensing robotic-assisted bronchoscopy is variable. Approximately half of proceduralists become facile with the technology within 25 lesions. After the initial learning phase, operators increasingly target lesions with more challenging features. Overall, these findings can inform certification and competency standards and provide new users with expectations related to performance over time.
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Affiliation(s)
- Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Nicolas Toumbacaris
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bryan C Husta
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin D Medina
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jason A Beattie
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert P Lee
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph Dycoco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mohit Chawla
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gaetano Rocco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Or Kalchiem-Dekel
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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6
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Kalifa J, Plat G, Brindel A, Héluain V, Brouchet L, Rouch A, Mazières J, Chapda MCP, Villeneuve T, Guibert N. Combination of electromagnetic navigation and probe-based LASER endomicroscopy to guide non-solid nodules sampling: Results from the CELTICS 2 study. Respir Med Res 2024; 85:101092. [PMID: 38657300 DOI: 10.1016/j.resmer.2024.101092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Jules Kalifa
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Gavin Plat
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Aurélien Brindel
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Valentin Héluain
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Laurent Brouchet
- Department of Thoracic Surgery, Toulouse University Hospital, Toulouse, France
| | - Axel Rouch
- Department of Thoracic Surgery, Toulouse University Hospital, Toulouse, France
| | - Julien Mazières
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Marie-Christelle Pajiep Chapda
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France; MeDatas, CIC (Centre d'Investigation Clinique), CHU Toulouse, Toulouse, France
| | - Thomas Villeneuve
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France
| | - Nicolas Guibert
- Department of Pulmonology, Toulouse University Hospital, Toulouse, France.
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7
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Leonard KM, Low SW, Echanique CS, Swanner BA, Johnson J, Dahlberg G, Paez R, Ratwani AP, Shojaee S, Rickman OB, Maldonado F, Lentz RJ. Diagnostic Yield vs Diagnostic Accuracy for Peripheral Lung Biopsy Evaluation: Evidence Supporting a Future Pragmatic End Point. Chest 2024; 165:1555-1562. [PMID: 38142773 DOI: 10.1016/j.chest.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 11/19/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Diagnostic yield and accuracy endpoints have been used inconsistently in the evaluation of advanced diagnostic bronchoscopy devices and techniques, limiting between-study comparisons. In addition, diagnostic accuracy can be adjudicated only after prolonged clinical follow-up, which delays reporting on the performance of novel devices. RESEARCH QUESTION Will a conservative diagnostic yield definition result in few false-negative initial results to closely approximate diagnostic accuracy and represent a useful outcome for future studies of diagnostic utility? METHODS Commonly used definitions of diagnostic yield were applied to a prospective data set of consecutive peripheral pulmonary lesions sampled by navigational bronchoscopy from 2017 to 2019. All consider malignancy to be diagnostic but differ in their classification of nonmalignant biopsy findings, which were subcategorized as specific benign, nonspecific benign, or normal lung. Diagnostic yield calculations were also compared with diagnostic accuracy, defined as the proportion of biopsy specimens deemed diagnostic by each definition that were confirmed accurate through 2 years of follow-up. RESULTS A total of 450 biopsy specimens of lesions were analyzed. The prevalence of malignancy was 60.9% (274 of 450). On initial bronchoscopy pathology, there were 227 malignant diagnoses (50.4%), with a single false positive (0.4%). Among 104 biopsy specimens with specific benign findings, only two were false negative for malignancy (1.9%). There were 119 nonspecific benign biopsy specimens, with 46 false negatives for malignancy (38.7%). The discrepancy between diagnostic yield and accuracy was 0.7% for the conservative definition, which only considered malignant or specific benign findings as diagnostic. INTERPRETATION A conservative diagnostic yield definition excluding nonspecific benign diagnoses closely approximated diagnostic accuracy through 2 years' follow-up, with a less than 1% discrepancy. Using this conservative yield definition may allow for dissemination of reliable diagnostic utility data without protracted delays needed for follow-up data in this era of rapid technological change in advanced diagnostic bronchoscopy.
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Affiliation(s)
- Kaele M Leonard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - See-Wei Low
- Division of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, OH
| | - Cristina Salmon Echanique
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Briana A Swanner
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joyce Johnson
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Greta Dahlberg
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Rafael Paez
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ankush P Ratwani
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Samira Shojaee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Otis B Rickman
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
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8
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Wang L, Cao J, Feng Y, Jia R, Ren Y. Application of uniportal video-assisted thoracoscopic surgery for segmentectomy in early-stage non-small cell lung cancer: A narrative review. Heliyon 2024; 10:e30735. [PMID: 38742067 PMCID: PMC11089358 DOI: 10.1016/j.heliyon.2024.e30735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/26/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
Uniportal video-assisted thoracoscopic surgery (UVATS) segmentectomy has emerged as an effective approach for managing early-stage non-small-cell lung cancer (NSCLC). Compared to conventional open and thoracoscopic surgeries, this minimally invasive surgical technique offers multiple benefits, including reduced postoperative discomfort, shorter hospital stays, expedited recovery, fewer complications, and superior cosmetic outcomes. Particularly advantageous in preserving lung function, UVATS segmentectomy is a compelling option for patients with compromised lung capabilities or limited pulmonary reserve. Notably, it demonstrates promising oncological results in early-stage NSCLC, with long-term survival rates comparable to those of lobectomies. Skilled thoracic surgeons can ensure a safe and effective execution of UVATS despite the potential technical challenges posed by complex tumor locations that may hinder visibility and maneuverability within the thoracic cavity. This study provided a comprehensive review of the literature and existing studies on UVATS segmentectomies. It delves into the evolution of the technique, its current applications, and the balance between its benefits and limitations. This discussion extends the technical considerations, challenges, and prospects of UVATS segmentectomy. Furthermore, it aimed to update advancements in segmentectomy for treating early-stage NSCLC, offering in-depth insights to thoracic surgeons to inform more scientifically grounded and patient-specific surgical decisions.
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Affiliation(s)
- Linlin Wang
- Department of Thoracic Surgery, Shenyang Tenth People's Hospital, Shenyang, Liaoning, China
| | - Jiandong Cao
- Department of Thoracic Surgery, Shenyang Tenth People's Hospital, Shenyang, Liaoning, China
| | - Yong Feng
- Department of Thoracic Surgery, Shenyang Tenth People's Hospital, Shenyang, Liaoning, China
| | - Renxiang Jia
- Department of Thoracic Surgery, Shenyang Tenth People's Hospital, Shenyang, Liaoning, China
| | - Yi Ren
- Department of Thoracic Surgery, Shenyang Tenth People's Hospital, Shenyang, Liaoning, China
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9
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Yuan M, Hu Y, Wang L, Yin W, Xiao Y. Diagnostic outcomes of radial endobronchial ultrasound bronchoscopy guided by manual navigation in the evaluation of peripheral pulmonary lesions: An observational study. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13768. [PMID: 38685753 PMCID: PMC11058397 DOI: 10.1111/crj.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND AIMS Manual navigation (MN), drawing a bronchoscopic road map simply by looking at the consecutive computed tomography (CT), is feasible and economical. However, scant data about the use of MN in radial endobronchial ultrasound (r-EBUS) bronchoscopy have been documented till now. We aimed to evaluate the diagnostic performance of r-EBUS bronchoscopy guided by MN for diagnosing peripheral pulmonary lesions (PPLs) and to determine clinical factors affecting the diagnostic yield. METHODS We performed a retrospective, cohort study of consecutive patients with PPLs who underwent r-EBUS bronchoscopic biopsy via guidance of MN from May 2020 to June 2021 in our Respiratory Endoscopic Division. The overall diagnostic yield of MN-guided r-EBUS, the factors affecting the yield, and the diagnostic performance for malignancy were evaluated. RESULTS A total of 102 patients (103 lesions) were evaluated. The overall diagnostic yield of MN-guided r-EBUS was 82.0%, and it ranged from 79.6% to 82.5%, assuming the undermined cases were all positive cases (79.6%) or negatives (82.5%). The sensitivity of MN-guided r-EBUS for malignancy was 71.4%, ranging from 68.2% to 71.4%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 67.3%, ranging from 63.8% to 69.0%. The multivariate logistic regression showed that "bronchus sign on CT" was the only predictor of the overall diagnostic yield (odds ratio = 11.5, 95% confidence interval: 1.9-70.9, P = 0.009). CONCLUSIONS MN-guided r-EBUS is feasible in diagnosing PPLs, especially for lesions with bronchus sign on CT.
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Affiliation(s)
- Mingli Yuan
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yi Hu
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Liangchao Wang
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Wen Yin
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yang Xiao
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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10
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Pritchett MA, Williams JC, Schirmer CC, Langereis S. Cone-beam CT-based Navigation With Augmented Fluoroscopy of the Airways for Image-guided Bronchoscopic Biopsy of Peripheral Pulmonary Nodules: A Prospective Clinical Study. J Bronchology Interv Pulmonol 2024; 31:175-182. [PMID: 37759354 DOI: 10.1097/lbr.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Cone-beam computed tomography (CBCT) and augmented fluoroscopy (AF), in which intraprocedural CBCT data is fused with fluoroscopy, have been utilized as a novel image-guidance technique for biopsy of peripheral pulmonary lesions. The aim of this clinical study is to determine the safety and diagnostic performance of CBCT-guided bronchoscopy with advanced software tools for procedural planning and navigational guidance with AF of the airways for biopsy of peripheral pulmonary nodules. METHODS Fifty-two consecutive subjects were prospectively enrolled in the AIRWAZE study (December 2018 to October 2019). Image-guided bronchoscopic biopsy procedures were performed under general anesthesia with specific ventilation protocols in a hybrid operating room equipped with a ceiling-mounted C-arm system. Procedural planning and image-guided bronchoscopy with CBCT and AF were performed using the Airwaze investigational device. RESULTS A total of 58 pulmonary lesions with a median size of 19.0 mm (range 7 to 48 mm) were biopsied. The overall diagnostic yield at index procedure was 87.9% (95% CI: 77.1%-94.0%). No severe adverse events related to CBCT-guided bronchoscopy, such as pneumothorax, bleeding, or respiratory failure, were observed. CONCLUSION CBCT-guided bronchoscopic biopsy with augmented fluoroscopic views of the airways and target lesion for navigational guidance is technically feasible and safe. Three-dimensional image-guided navigation biopsy is associated with high navigational success and a high diagnostic yield for peripheral pulmonary nodules.
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Affiliation(s)
| | | | - Charles C Schirmer
- Pathology, FirstHealth of the Carolinas & Pinehurst Medical Clinic, Pinehurst, NC
| | - Sander Langereis
- Department of Clinical Science IGT-S, Philips Medical Systems, Best, The Netherlands
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11
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Zhang J, Chen E, Xu S, Xu L, Hu H, Dong L, Ying K. Virtual bronchoscopic navigation with intraoperative cone-beam CT for the diagnosis of peripheral pulmonary nodules. BMC Pulm Med 2024; 24:146. [PMID: 38509516 PMCID: PMC10956201 DOI: 10.1186/s12890-024-02930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Transbronchial biopsy is a safe manner with fewer complications than percutaneous transthoracic needle biopsy; however, the current diagnostic yield is still necessitating further improvement. We aimed to evaluate the diagnostic yield of using virtual bronchoscopic navigation (VBN) and cone-beam CT (CBCT) for transbronchial biopsy and to investigate the factors that affected the diagnostic sensitivity. METHODS We retrospectively investigated 255 patients who underwent VBN-CBCT-guided transbronchial biopsy at our two centers from May 2021 to April 2022. A total of 228 patients with final diagnoses were studied. Patient characteristics including lesion size, lesion location, presence of bronchus sign, lesion type and imaging tool used were collected and analyzed. Diagnostic yield was reported overall and in groups using different imaging tools. RESULTS The median size of lesion was 21 mm (range of 15.5-29 mm) with 46.1% less than 2 cm in diameter. Bronchus sign was present in 87.7% of the patients. The overall diagnostic yield was 82.1%, and sensitivity for malignancy was 66.3%. Patients with lesion > 2 cm or with bronchus sign were shown to have a significantly higher diagnostic yield. Four patients had bleeding and no pneumothorax occurred. CONCLUSION Guided bronchoscopy with VBN and CBCT was an effective diagnostic method and was associated with a high diagnostic yield in a safe manner. In addition, the multivariant analysis suggested that lesion size and presence of bronchus sign could be a predictive factor for successful bronchoscopic diagnosis.
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Affiliation(s)
- Jisong Zhang
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Enguo Chen
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Shan Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Li Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Huihui Hu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Liangliang Dong
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Kejing Ying
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China.
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12
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Xu D, Xie F, Zhang J, Chen H, Chen Z, Guan Z, Hou G, Ji C, Li H, Li M, Li W, Li X, Li Y, Lian H, Liao J, Liu D, Luo Z, Ouyang H, Shen Y, Shi Y, Tang C, Wan N, Wang T, Wang H, Wang H, Wang J, Wu X, Xia Y, Xiao K, Xu W, Xu F, Yang H, Yang J, Ye T, Ye X, Yu P, Zhang N, Zhang P, Zhang Q, Zhao Q, Zheng X, Zou J, Chen E, Sun J. Chinese expert consensus on cone-beam CT-guided diagnosis, localization and treatment for pulmonary nodules. Thorac Cancer 2024; 15:582-597. [PMID: 38337087 PMCID: PMC10912555 DOI: 10.1111/1759-7714.15222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 02/12/2024] Open
Abstract
Cone-beam computed tomography (CBCT) system can provide real-time 3D images and fluoroscopy images of the region of interest during the operation. Some systems can even offer augmented fluoroscopy and puncture guidance. The use of CBCT for interventional pulmonary procedures has grown significantly in recent years, and numerous clinical studies have confirmed the technology's efficacy and safety in the diagnosis, localization, and treatment of pulmonary nodules. In order to optimize and standardize the technical specifications of CBCT and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Interventional Pulmonology of China Association for Promotion of Health Science and Technology.
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Affiliation(s)
- Dongyang Xu
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Jisong Zhang
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory DiseaseSir Run Run Shaw Hospital of Zhejiang UniversityHangzhouChina
| | - Hong Chen
- Department of Pulmonary and Critical Care MedicineSecond Affiliated Hospital of Harbin Medical UniversityHarbinChina
| | - Zhongbo Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical SchoolNingbo UniversityNingboChina
| | - Zhenbiao Guan
- Department of Respiration, Changhai HospitalNaval Medical UniversityShanghaiChina
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, China‐Japan Friendship HospitalBeijingChina
| | - Cheng Ji
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Haitao Li
- Department of Respiratory and Critical Care MedicineThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Manxiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Wei Li
- Department of Respiratory DiseaseThe First Affiliated Hospital of Bengbu Medical CollegeBengbuChina
| | - Xuan Li
- Department of Respiratory Medicine, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Yishi Li
- Dept of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hairong Lian
- Department of Respiratory MedicineAffiliated Hospital of Jiangnan UniversityWuxiChina
| | - Jiangrong Liao
- Department of Respiratory MedicineGuizhou Aerospace HospitalZunyiChina
| | - Dan Liu
- Department of Respiratory and Critical Care MedicineWest China Hospital of Sichuan UniversityChengduChina
| | - Zhuang Luo
- Department of Respiratory and Critical Care MedicineFirst Affiliated Hospital of Kunming Medical UniversityKunmingChina
| | - Haifeng Ouyang
- Department of Respiratory DiseasesXi'an International Medical CenterXi'anChina
| | - Yongchun Shen
- Department of Respiratory and Critical Care MedicineWest China Hospital of Sichuan UniversityChengduChina
| | - Yiwei Shi
- Department of Respiratory and Critical Care MedicineShanxi Medical University Affiliated First HospitalTaiyuanChina
| | - Chunli Tang
- China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory DiseaseThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Nansheng Wan
- Department of Respiratory and Critical Care MedicineTianjin Medical University General HospitalTianjinChina
| | - Tao Wang
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Hong Wang
- Department of Respiratory MedicineLanzhou University Second HospitalLanzhouChina
| | - Huaqi Wang
- Department of Respiratory MedicineThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Juan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xuemei Wu
- Department of Respiratory CentreThe Second Affiliated Hospital of Xiamen Medical CollegeXiamenChina
| | - Yang Xia
- Department of Respiratory and Critical Care MedicineSecond Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
| | - Kui Xiao
- Department of Respiratory Medicine, The Second Xiangya HospitalCentral South UniversityChangshaChina
| | - Wujian Xu
- Department of Respiratory and Critical Care Medicine, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Fei Xu
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Huizhen Yang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou UniversityZhengzhouChina
| | - Junyong Yang
- Department of Respiratory MedicineXinjiang Chest HospitalWulumuqiChina
| | - Taosheng Ye
- Department of TuberculosisThe Third People's Hospital of ShenzhenShenzhenChina
| | - Xianwei Ye
- Department of Pulmonary and Critical Care MedicineGuizhou Provincial People's HospitalGuiyangChina
| | - Pengfei Yu
- Department of Respiratory and Critical Care Medicine, Yantai Yuhuangding HospitalAffiliated with the Medical College of QingdaoYantaiChina
| | - Nan Zhang
- Department of Respiratory Medicine, Emergency General HospitalBeijingChina
| | - Peng Zhang
- Pulmonary Intervention DepartmentAnhui Chest HospitalHefeiChina
| | - Quncheng Zhang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou UniversityZhengzhouChina
| | - Qi Zhao
- Department of Respiratory Medicine, Nanjing Drum Tower HospitalNanjing University Medical SchoolNanjingChina
| | - Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Jun Zou
- Department of Respiratory and Critical Care Medicine, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Enguo Chen
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory DiseaseSir Run Run Shaw Hospital of Zhejiang UniversityHangzhouChina
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
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13
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Gesthalter YB, Channick CL. Interventional Pulmonology: Extending the Breadth of Thoracic Care. Annu Rev Med 2024; 75:263-276. [PMID: 37827195 DOI: 10.1146/annurev-med-050922-060929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Interventional pulmonary medicine has developed as a subspecialty focused on the management of patients with complex thoracic disease. Leveraging minimally invasive techniques, interventional pulmonologists diagnose and treat pathologies that previously required more invasive options such as surgery. By mitigating procedural risk, interventional pulmonologists have extended the reach of care to a wider pool of vulnerable patients who require therapy. Endoscopic innovations, including endobronchial ultrasound and robotic and electromagnetic bronchoscopy, have enhanced the ability to perform diagnostic procedures on an ambulatory basis. Therapeutic procedures for patients with symptomatic airway disease, pleural disease, and severe emphysema have provided the ability to palliate symptoms. The combination of medical and procedural expertise has made interventional pulmonologists an integral part of comprehensive care teams for patients with oncologic, airway, and pleural needs. This review surveys key areas in which interventional pulmonologists have impacted the care of thoracic disease through bronchoscopic intervention.
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Affiliation(s)
- Yaron B Gesthalter
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA;
| | - Colleen L Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA;
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14
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Shaller BD, Sethi S, Cicenia J. Imaging in peripheral bronchoscopy. Curr Opin Pulm Med 2024; 30:17-24. [PMID: 37933680 DOI: 10.1097/mcp.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Historically the sampling of peripheral lung lesions via bronchoscopy has suffered from inferior diagnostic outcomes relative to transthoracic needle aspiration, and neither a successful bronchoscopic navigation nor a promising radial ultrasonographic image of one's target lesion guarantees a successful biopsy. Fortunately, many of peripheral bronchoscopy's shortcomings - including an inability to detect and compensate for computed tomography (CT)-body divergence, and the absence of tool-in-lesion confirmation - are potentially remediable through the use of improved intraprocedural imaging techniques. RECENT FINDINGS Recent advances in intraprocedural imaging, including the integration of cone beam CT, digital tomosynthesis, and augmented fluoroscopy into bronchoscopic procedures have yielded promising results. These advanced imaging modalities may improve the outcomes of peripheral bronchoscopy through the detection and correction of navigational errors, CT-body divergence, and malpositioned biopsy instruments. SUMMARY The incorporation of advanced imaging is an essential step in the improvement of peripheral bronchoscopic procedures.
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Affiliation(s)
- Brian D Shaller
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonali Sethi
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Cicenia
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Bhadra K, Rickman OB, Mahajan AK, Hogarth DK. "Tool-in-lesion" Accuracy of Galaxy System-A Robotic Electromagnetic Navigation BroncHoscopy With Integrated Tool-in-lesion-Tomosynthesis Technology: The MATCH Study. J Bronchology Interv Pulmonol 2024; 31:23-29. [PMID: 37072895 PMCID: PMC10763708 DOI: 10.1097/lbr.0000000000000923] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/21/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The Galaxy System (Noah Medical) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct computerized tomography (CT) to body divergence and novel confirmation of tool-in-lesion (TIL). The primary aim of this study was to assess the TIL accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHODS Four operators conducted the experiment using 4 pigs. Each physician performed between 4 and 6 nodule biopsies for 20 simulated lung nodules with purple dye and a radio pacifier. Using Galaxy's "Tool-in-Lesion Tomography (TOMO+)" with augmented fluoroscopy, the physician navigated to the lung nodules, and a tool (needle) was placed into the lesion. TIL was defined by the needle in the lesion determined by cone-beam CT. RESULTS The lung nodule's average size was 16.3 ± 0.97 mm and was predominantly in the lower lobes (65%). All 4 operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). TIL after the final TOMO sweep was 95% (19/20) and tool-touch-lesion was 5% (1/20). Biopsy yielding purple pigmentation was also 100% (20/20). CONCLUSION The Galaxy System demonstrated successful digital TOMO confirmed TIL success in 95% (19/20) of lesions and tool-touch-lesion in 5% (1/20) as confirmed by cone-beam CT. Successful diagnostic yield was achieved in 100% (20/20) of lesions as confirmed by intralesional pigment acquisition.
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Affiliation(s)
- Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga
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16
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Graham J, Basist M, Frye L, Agrawal A, Nasim F. Advances in navigating to the nodule and targeting. Curr Opin Pulm Med 2024; 30:9-16. [PMID: 37930633 DOI: 10.1097/mcp.0000000000001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW The multitude of available platforms and imaging modalities for navigational bronchoscopy, in combination with the various sampling tools that can be used intra-procedurally, is complex. This review seeks to describe the recent developments in peripheral bronchoscopy in regards to navigation, imaging, and sampling target lesions in the pulmonary parenchyma. RECENT FINDINGS Robotic assisted bronchoscopy has improved navigation to the peripheral airways for sampling of peripheral parenchymal lesions. These navigational platforms use innovative technology utilizing electromagnetic navigation and shape-sensing technology for guidance. The greatest improvement has been the stabilization of the robotic scope in the periphery to allow for accurate sampling. Despite improvements in these platforms, limitations of CT to body divergence continue to impact navigation to the lesion and therefore diagnostic yield of the procedure. Advanced intraprocedural imaging with cone beam CT or augmented fluoroscopy has been a recent focus to improve this area. Further, the adoption of newer sampling tools, such as cryobiopsy, offers the possibility of increased diagnostic yield. SUMMARY The developments in advanced bronchoscopy will impact the role of biopsy in the diagnosis of peripheral pulmonary parenchymal lesions.
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Affiliation(s)
- Jeffrey Graham
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Madeleine Basist
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Laura Frye
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Faria Nasim
- Interventional Pulmonology, Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Li Y, Chen W, Xie F, Huang R, Liu X, Xiao Y, Cao L, Hu Y, Ke M, Wu S, Sun J. Novel electromagnetic navigation bronchoscopy system for the diagnosis of peripheral pulmonary nodules: a prospective, multicentre study. Thorax 2023; 78:1197-1205. [PMID: 37734951 PMCID: PMC10715528 DOI: 10.1136/thorax-2022-219664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 08/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Traditional electromagnetic navigation bronchoscopy (ENB) is a real-time image-guided system and used with thick bronchoscopes for the diagnosis of peripheral pulmonary nodules (PPNs). A novel ENB that could be used with thin bronchoscopes was developed. This study aimed to evaluate the diagnostic yield and the experience of using this ENB system in a real clinical scenario. METHODS This multicentre study enrolled consecutive patients with PPNs adopting ENB from March 2019 to August 2021. ENB was performed with different bronchoscopes, ancillary techniques and sampling instruments according to the characteristics of the nodule and the judgement of the operator. The primary endpoint was the diagnostic yield. The secondary endpoints included the diagnostic yield of subgroups, procedural details and complication rate. RESULTS In total, 479 patients with 479 nodules were enrolled in this study. The median lesion size was 20.9 (IQR, 15.9-25.9) mm. The overall diagnostic yield was 74.9% (359/479). A thin bronchoscope was used in 96.2% (461/479) nodules. ENB in combination with radial endobronchial ultrasound (rEBUS), a guide sheath (GS) and a thin bronchoscope was the most widely used guided method, producing a diagnostic yield of 74.1% (254/343). The median total procedural time was 1325.0 (IQR, 1014.0-1676.0) s. No severe complications occurred. CONCLUSION This novel ENB system can be used in combination with different bronchoscopes, ancillary techniques and sampling instruments with a high diagnostic yield and safety profile for the diagnosis of PPNs, of which the combination of thin bronchoscope, rEBUS and GS was the most common method in clinical practice. TRIAL REGISTRATION NUMBER NCT03716284.
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Affiliation(s)
- Ying Li
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Wei Chen
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Rui Huang
- Department of Respiratory Centre, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian, China
| | - Xiang Liu
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yang Xiao
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liming Cao
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi Hu
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Mingyao Ke
- Department of Respiratory Centre, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian, China
| | - Shiman Wu
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
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18
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Ali MS, Ghori UK, Wayne MT, Shostak E, De Cardenas J. Diagnostic Performance and Safety Profile of Robotic-assisted Bronchoscopy: A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2023; 20:1801-1812. [PMID: 37769170 DOI: 10.1513/annalsats.202301-075oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/27/2023] [Indexed: 09/30/2023] Open
Abstract
Rationale: Conventional electromagnetic navigation bronchoscopy and other guided bronchoscopic modalities have a very desirable safety profile, but their diagnostic yield is only 60-70% for pulmonary lesions. Recently, robotic-assisted bronchoscopy (RAB) platforms have been introduced to improve the diagnostic performance of bronchoscopic modalities. Objectives: To determine the diagnostic performance and safety profile of RAB (using shape-sensing and electromagnetic navigation-based platforms) by performing a systematic review and meta-analysis. Methods: The PubMed, Embase, and Google Scholar databases were searched to find studies that reported on the diagnostic performance and/or the safety profile of one of the RAB systems. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was performed using MedCalc version 20.118. Pooled diagnostic yield was calculated using a Freeman-Tukey transformation. We planned to use a random-effects model if the I2 index was >40%. Results: Twenty-five studies were included: 20 including diagnostic and safety analyses and 5 including only safety analyses. The pooled diagnostic yield of RAB (20 studies, 1,779 lesions) was 84.3% (95% confidence interval, 81.1-87.2%). The I2 index was 65.6%. On the basis of our subgroup analyses, the heterogeneity was likely driven by differences in study designs (prospective vs. retrospective) and procedural protocols (such as different RAB systems). Lesion size > 2 cm, the presence of a computed tomography bronchus sign, and concentric radial endobronchial ultrasound view were associated with a statistically significant increase in the odds of diagnosis with RAB. The overall rates of pneumothorax, need for tube thoracostomy, and significant hemorrhage were 2.3%, 1.2%, and 0.5%, respectively. Conclusions: RAB systems have significantly increased the diagnostic yield of navigational bronchoscopy compared with conventional systems such as electromagnetic navigation bronchoscopy, but well-designed prospective studies are needed to better understand the impact of various factors, such as the use of three-dimensional imaging modalities, cryobiopsy, and specific ventilatory protocols, on the diagnostic yield of RAB.
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Affiliation(s)
- Muhammad Sajawal Ali
- Division of Pulmonary and Critical Care Medicine
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Uzair Khan Ghori
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Max Theodore Wayne
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Eugene Shostak
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Jose De Cardenas
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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19
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Brownlee AR, Watson JJ, Akhmerov A, Nammalwar S, Chen Q, Soukiasian SG, Soukiasian HJ. Robotic navigational bronchoscopy in a thoracic surgery practice: Leveraging technology in the management of pulmonary nodules. JTCVS OPEN 2023; 16:1-6. [PMID: 38204680 PMCID: PMC10774940 DOI: 10.1016/j.xjon.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 01/12/2024]
Abstract
Objectives Robotic navigational bronchoscopy is increasingly used to improve diagnostic yield for pulmonary nodules compared with the 50% to 60% obtained by standard bronchoscopy; however, safety and efficacy data are limited to small series. The aim of this study was to evaluate diagnostic yield and clinical outcomes in a large multisurgeon single-center cohort. Methods All patients who underwent robotic navigational bronchoscopy and biopsy from September 2020 to October 2022 were identified from a prospective institutional registry. The primary outcome was diagnostic yield. The secondary outcome was diagnostic yield for molecular testing. Results A total of 503 nodules were biopsied during the study period. Median nodule size was 2.1 cm. Overall diagnostic yield was 87.9%. Factors associated with increased diagnostic yield were decreased time from date of planning computed tomography to procedure date (odds ratio, 0.98; 95% CI, 0.96-0.99; P = .04) and greater nodule size (odds ratio, 1.03; 95% CI, 1.01-1.07; P = .02) per 0.1-cm increment. Molecular analysis was sent in 101 patients and was sufficient in 90% of cases. Complications occurred in 22 (5%) patients, including 13 (3.1%) with pneumothoraxes (7 patients requiring a chest drain), and 5 (1.2%) patients had bleeding requiring intraprocedural bronchial intervention. A total of 41 patients were consented for biopsy and resection during a single anesthetic event. Four of these cases were stopped at robotic navigational bronchoscopy due to an alternative diagnosis. Mean length of stay was 3.4 ± 1.1 days. There were no major complications. Conclusions This study suggests robotic navigational bronchoscopy has a high diagnostic yield and obtains adequate tissue for molecular analysis critical for selection of targeted therapies. With careful patient selection robotic navigational bronchoscopy can be combined with surgery to treat lung cancer as a single procedure with low complication rates.
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Affiliation(s)
- Andrew R. Brownlee
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Justin J.J. Watson
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Akbarshakh Akhmerov
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Shruthi Nammalwar
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Qiudong Chen
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Sevannah G. Soukiasian
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Harmik J. Soukiasian
- Division of Thoracic Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
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20
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Lachkar S, Guisier F, Thiberville L, Dantoing E, Salaün M. [Advanced bronchoscopic techniques for the diagnosis of peripheral lung nodule]. Rev Mal Respir 2023; 40:810-819. [PMID: 37798173 DOI: 10.1016/j.rmr.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/25/2023] [Indexed: 10/07/2023]
Abstract
The endoscopic diagnosis of peripheral lung nodules is a challenging aspect of oncological practice. More often than not inaccessible by traditional endoscopy, these nodules necessitate multiple imagery tests, as well as diagnostic surgery for benign lesions. Even though transthoracic ultrasonography has a high diagnostic yield, a sizeable complication rate renders it suboptimal. Over recent years, a number of safe and accurate navigational bronchoscopic procedures have been developed. In this first part, we provide an overview of the bronchoscopic techniques currently applied for the excision and diagnostic analysis of peripheral lung nodules; emphasis is laid on electromagnetic navigation bronchoscopy and the association of virtual bronchoscopy planner with radial endobronchial ultrasound. We conclude by considering recent innovations, notably robotic bronchoscopy.
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Affiliation(s)
- S Lachkar
- Department of Pneumology, CHU de Rouen, 76000 Rouen, France.
| | - F Guisier
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
| | - L Thiberville
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
| | - E Dantoing
- Department of Pneumology, CHU de Rouen, 76000 Rouen, France
| | - M Salaün
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
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21
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Vu LH, Yu Lee-Mateus A, Edell ES, Hartley C, Vierkant RA, Fernandez-Bussy S, Reisenauer J. Accuracy of Preliminary Pathology for Robotic Bronchoscopic Biopsy. Ann Thorac Surg 2023; 116:1028-1034. [PMID: 36470566 DOI: 10.1016/j.athoracsur.2022.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/24/2022] [Accepted: 11/11/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diagnosis and treatment of peripheral pulmonary lesions (PPLs) currently require at least 2 procedures. An all-in-1 approach would require diagnosing malignancy with preliminary cytology results. This study investigated the concordance between preliminary cytology and final pathology results in biopsies of PPLs obtained by shape-sensing robotic-assisted bronchoscopy (ssRAB). METHODS This study was a retrospective, consecutive, single-arm, single-center study of 110 ssRABs for PPLs. Concordance was defined as agreement between preliminary cytology and final pathology results. Accuracy, sensitivity, specificity, positive and negative predictive values, and safety outcomes were examined. RESULTS The concordance was 89% for needle biopsies, 85% for forceps biopsies, and 92% overall, with substantial agreement. There was no significant association of concordance with patients' demographics or lesion characteristics. Preliminary cytology resulted in a malignant diagnosis in 70%, a nonmalignant diagnosis in 4%, and a nondiagnostic result in 26%, with accuracy of 86% and sensitivity of 84%. The total complication rate was 3.6%, with a pneumothorax rate of 1.8%. CONCLUSIONS This study compared the concordance of preliminary pathology results with final pathology results for ssRAB biopsies in PPLs. The results showed that preliminary samples have a high concordance with final pathology results and may enable management of PPLs with a single anesthetic procedure including biopsy, staging, and treatment.
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Affiliation(s)
- Linh H Vu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alejandra Yu Lee-Mateus
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Sebastian Fernandez-Bussy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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22
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Thiboutot J, Pastis NJ, Akulian J, Silvestri GA, Chen A, Wahidi MM, Gilbert CR, Lin CT, Los J, Flenaugh E, Semaan R, Burks AC, Sathyanarayan P, Wu S, Feller-Kopman D, Cheng GZ, Alalawi R, Rahman NM, Maldonado F, Lee HJ, Yarmus L. A Multicenter, Single-Arm, Prospective Trial Assessing the Diagnostic Yield of Electromagnetic Bronchoscopic and Transthoracic Navigation for Peripheral Pulmonary Nodules. Am J Respir Crit Care Med 2023; 208:837-845. [PMID: 37582154 DOI: 10.1164/rccm.202301-0099oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 08/15/2023] [Indexed: 08/17/2023] Open
Abstract
Rationale: Strict adherence to procedural protocols and diagnostic definitions is critical to understand the efficacy of new technologies. Electromagnetic navigational bronchoscopy (ENB) for lung nodule biopsy has been used for decades without a solid understanding of its efficacy, but offers the opportunity for simultaneous tissue acquisition via electromagnetic navigational transthoracic biopsy (EMN-TTNA) and staging via endobronchial ultrasound (EBUS). Objective: To evaluate the diagnostic yield of EBUS, ENB, and EMN-TTNA during a single procedure using a strict a priori definition of diagnostic yield with central pathology adjudication. Methods: A prospective, single-arm trial was conducted at eight centers enrolling participants with pulmonary nodules (<3 cm; without computed tomography [CT]- and/or positron emission tomography-positive mediastinal lymph nodes) who underwent a staged procedure with same-day CT, EBUS, ENB, and EMN-TTNA. The procedure was staged such that, when a diagnosis had been achieved via rapid on-site pathologic evaluation, the procedure was ended and subsequent biopsy modalities were not attempted. A study finding was diagnostic if an independent pathology core laboratory confirmed malignancy or a definitive benign finding. The primary endpoint was the diagnostic yield of the combination of CT, EBUS, ENB, and EMN-TTNA. Measurements and Main Results: A total of 160 participants at 8 centers with a mean nodule size of 18 ± 6 mm were enrolled. The diagnostic yield of the combined procedure was 59% (94 of 160; 95% confidence interval [CI], 51-66%). Nodule regression was found on same-day CT in 2.5% of cases (4 of 160; 95% CI, 0.69-6.3%), and EBUS confirmed malignancy in 7.1% of cases (11 of 156; 95% CI, 3.6-12%). The yield of ENB alone was 49% (74 of 150; 95% CI, 41-58%), that of EMN-TTNA alone was 27% (8 of 30; 95% CI, 12-46%), and that of ENB plus EMN-TTNA was 53% (79 of 150; 95% CI, 44-61%). Complications included a pneumothorax rate of 10% and a 2% bleeding rate. When EMN-TTNA was performed, the pneumothorax rate was 30%. Conclusions: The diagnostic yield for ENB is 49%, which increases to 59% with the addition of same-day CT, EBUS, and EMN-TTNA, lower than in prior reports in the literature. The high complication rate and low diagnostic yield of EMN-TTNA does not support its routine use. Clinical trial registered with www.clinicaltrials.gov (NCT03338049).
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Affiliation(s)
| | - Nicholas J Pastis
- Division of Pulmonary and Critical Care Medicine, Ohio State University, Columbus, Ohio
| | - Jason Akulian
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Momen M Wahidi
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Christopher R Gilbert
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Cheng Ting Lin
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - Jenna Los
- Division of Pulmonary and Critical Care Medicine and
| | - Eric Flenaugh
- Division of Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Roy Semaan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - A Cole Burks
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sam Wu
- Division of Pulmonary and Critical Care Medicine and
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Dartmouth College, Hanover, New Hampshire
| | - George Z Cheng
- Division of Pulmonary and Critical and Sleep Medicine, University of California, San Diego, California
| | - Raed Alalawi
- Division of Pulmonary and Critical Care Medicine, University of Arizona, Tucson, Arizona
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom; and
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hans J Lee
- Division of Pulmonary and Critical Care Medicine and
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine and
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23
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Magnini D, Sotgiu G, Bello G, Puci M, Livi V, Dell’Anna AM, De Santis P, Dell’Ariccia R, Viscuso M, Flore MC, Bisanti A, Paioli D, Gullì A, Leoncini F, Antonelli M, Trisolini R. Thirty-Day Complications, Unplanned Hospital Encounters, and Mortality after Endosonography and/or Guided Bronchoscopy: A Prospective Study. Cancers (Basel) 2023; 15:4531. [PMID: 37760500 PMCID: PMC10526926 DOI: 10.3390/cancers15184531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/27/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Limited data exist regarding the adverse events of advanced diagnostic bronchoscopy, with most of the available information derived from retrospective datasets that primarily focus on early complications. METHODS We conducted a 15-month prospective cohort study among consecutive patients undergoing endosonography and/or guided bronchoscopy under general anesthesia. We evaluated the 30-day incidence of severe complications, any complication, unplanned hospital encounters, and deaths. Additionally, we analyzed the time of onset (immediate, within 1 h of the procedure; early, 1 h-24 h; late, 24 h-30 days) and identified risk factors associated with these events. RESULTS Thirty-day data were available for 697 out of 701 (99.4%) enrolled patients, with 85.6% having suspected malignancy and multiple comorbidities (median Charlson Comorbidity Index (IQR): 4 (2-5)). Severe complications occurred in only 17 (2.4%) patients, but among them, 10 (58.8%) had unplanned hospital encounters and 2 (11.7%) died within 30 days. A significant proportion of procedure-related severe complications (8/17, 47.1%); unplanned hospital encounters (8/11, 72.7%); and the two deaths occurred days or weeks after the procedure. Low-dose attenuation in the biopsy site on computed tomography was independently associated with any complication (OR: 1.87; 95% CI 1.13-3.09); unplanned hospital encounters (OR: 2.17; 95% CI 1.10-4.30); and mortality (OR: 4.19; 95% CI 1.74-10.11). CONCLUSIONS Severe complications arising from endosonography and guided bronchoscopy, although uncommon, have significant clinical consequences. A substantial proportion of adverse events occur days after the procedure, potentially going unnoticed and exerting a negative clinical impact if a proactive surveillance program is not implemented.
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Affiliation(s)
- Daniele Magnini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (G.S.); (M.P.)
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
| | - Mariangela Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (G.S.); (M.P.)
| | - Vanina Livi
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
| | - Antonio Maria Dell’Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
| | - Paolo De Santis
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
| | - Ruben Dell’Ariccia
- Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (R.D.); (M.V.)
| | - Marta Viscuso
- Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (R.D.); (M.V.)
| | - Maria Chiara Flore
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
| | - Alessandra Bisanti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
| | - Daniela Paioli
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
| | - Antonio Gullì
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
| | - Fausto Leoncini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (A.M.D.); (P.D.S.); (A.B.); (A.G.); (M.A.)
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Hearth, 00168 Rome, Italy
| | - Rocco Trisolini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (D.M.); (V.L.); (M.C.F.); (D.P.); (F.L.)
- Department of Anesthesiology and Critical Care Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
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Ortiz-Jaimes G, Reisenauer J. Real-World Impact of Robotic-Assisted Bronchoscopy on the Staging and Diagnosis of Lung Cancer: The Shape of Current and Potential Opportunities. Pragmat Obs Res 2023; 14:75-94. [PMID: 37694262 PMCID: PMC10492559 DOI: 10.2147/por.s395806] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
The approach to peripheral pulmonary lesions (PPL) has been evolving continuously. Advanced bronchoscopic navigational techniques have improved the airway-based approaches to these lesions. Robotic Assisted Bronchoscopy (RAB) can be considered the current pinnacle of this evolution; allowing for a safer approach to sampling lesions previously considered outside of bronchoscopic reach. We present a comprehensive review of the changing epidemiology of lung cancer and the importance of early tissue sampling, the evolution of sampling and navigational bronchoscopic techniques, technical considerations and evidence pertaining to the use of RAB, and adjunct techniques in the diagnosis of lung cancer. Complications and future applications of RAB are also discussed.
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Affiliation(s)
- Gabriel Ortiz-Jaimes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
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25
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Farina L, Ruvio G, Shatwan R, Shalaby A, O'Halloran M, White A, Soo A, Breen D, Lowery A, Quinn AM. Histology-Validated Dielectric Characterisation of Lung Carcinoma Tissue for Microwave Thermal Ablation Applications. Cancers (Basel) 2023; 15:3738. [PMID: 37509399 PMCID: PMC10378338 DOI: 10.3390/cancers15143738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Microwave thermal ablation is a promising emerging treatment for early-stage lung cancer. Applicator design optimisation and treatment planning rely on accurate knowledge of dielectric tissue properties. Limited dielectric data are available in the literature for human lung tissue and pulmonary tumours. In this work, neoplastic and non-neoplastic lung dielectric properties are characterised and correlated with gross and histological morphology. Fifty-six surgical specimens were obtained from twelve patients undergoing lung resection for lung cancer in University Hospital of Galway, Ireland. Dielectric spectroscopy in the microwave frequency range (500 MHz-8.5 GHz) was performed on the ex vivo lung specimens with the open-ended coaxial probe technique (in the Department of Pathology). Dielectric data were analysed and correlated with the tissue histology. The dielectric properties of twelve lung tumours (67% non-small cell carcinoma (NSCC)) and uninvolved lung parenchyma were obtained. The values obtained from the neoplastic lung specimens (relative permittivity: 52.0 ± 5.4, effective conductivity: 1.9 ± 0.2 S/m, at 2.45 GHz) were on average twice the value of the non-neoplastic lung specimens (relative permittivity: 28.3 ± 6.7, effective conductivity: 1.0 ± 0.3 S/m, at 2.45 GHz). Dense fibrosis was comparable with tumour tissue (relative permittivity 49.3 ± 4.6, effective conductivity: 1.8 ± 0.1 S/m, at 2.45 GHz).
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Affiliation(s)
- Laura Farina
- R & D, Endowave Ltd., H91 DCH9 Galway, Ireland
- College of Medicine, Nursing and Health Sciences, University of Galway, H91 TK33 Galway, Ireland
| | | | - Ramadan Shatwan
- Department of Anatomic Pathology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Aliaa Shalaby
- Department of Anatomic Pathology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Martin O'Halloran
- College of Medicine, Nursing and Health Sciences, University of Galway, H91 TK33 Galway, Ireland
| | - Alexandra White
- Department of Cardiothoracic Surgery, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David Breen
- Interventional Respiratory Unit, Department Respiratory Medicine, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Aoife Lowery
- Discipline of Surgery, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Anne Marie Quinn
- Department of Anatomic Pathology, Galway University Hospital, H91 YR71 Galway, Ireland
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Catarata MJ, Van Geffen WH, Banka R, Ferraz B, Sidhu C, Carew A, Viola L, Gijtenbeek R, Hardavella G. ERS International Congress 2022: highlights from the Thoracic Oncology Assembly. ERJ Open Res 2023; 9:00579-2022. [PMID: 37583965 PMCID: PMC10423989 DOI: 10.1183/23120541.00579-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/31/2023] [Indexed: 08/17/2023] Open
Abstract
Thoracic malignancies are associated with a substantial public health burden. Lung cancer is the leading cause of cancer-related mortality worldwide, with significant impact on patients' quality of life. Following 2 years of virtual European Respiratory Society (ERS) Congresses due to the COVID-19 pandemic, the 2022 hybrid ERS Congress in Barcelona, Spain allowed peers from all over the world to meet again and present their work. Thoracic oncology experts presented best practices and latest developments in lung cancer screening, lung cancer diagnosis and management. Early lung cancer diagnosis, subsequent pros and cons of aggressive management, identification and management of systemic treatments' side-effects, and the application of artificial intelligence and biomarkers across all aspects of the thoracic oncology pathway were among the areas that triggered specific interest and will be summarised here.
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Affiliation(s)
- Maria Joana Catarata
- Pulmonology Department, Hospital de Braga, Braga, Portugal
- Tumour & Microenvironment Interactions Group, I3S-Institute for Health Research & Innovation, University of Porto, Porto, Portugal
| | - Wouter H. Van Geffen
- Department of Respiratory Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Radhika Banka
- P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Beatriz Ferraz
- Pulmonology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
| | | | - Alan Carew
- Queensland Lung Transplant Service, Department of Thoracic Medicine, Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Lucia Viola
- Thoracic Oncology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
- Thoracic Clinic, Luis Carlos Sarmiento Angulo Cancer Treatment and Research Center (Fundación CTIC), Bogotá, Colombia
| | - Rolof Gijtenbeek
- Department of Respiratory Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Georgia Hardavella
- 9th Department of Respiratory Medicine, “Sotiria” Athens Chest Diseases Hospital, Athens, Greece
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Swenson KE, DuComb EA, Abia-Trujillo D, Majid A, Parikh MS. Image-guided Bronchoscopy: Established and Emerging Approaches. Am J Respir Crit Care Med 2023; 208:98-100. [PMID: 37129567 DOI: 10.1164/rccm.202205-1008rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 05/01/2023] [Indexed: 05/03/2023] Open
Affiliation(s)
- Kai E Swenson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emily A DuComb
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - David Abia-Trujillo
- Interventional Pulmonology Section, Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mihir S Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Nadig TR, Thomas N, Nietert PJ, Lozier J, Tanner NT, Wang Memoli JS, Pastis NJ, Silvestri GA. Guided Bronchoscopy for the Evaluation of Pulmonary Lesions: An Updated Meta-analysis. Chest 2023; 163:1589-1598. [PMID: 36640994 PMCID: PMC10925546 DOI: 10.1016/j.chest.2022.12.044] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Tejaswi R Nadig
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC
| | - Nina Thomas
- Division of Pulmonary Disease & Critical Care, University of Colorado, Aurora, CO
| | - Paul J Nietert
- Department of Public Health Sciences, MUSC, Charleston, SC
| | - Jessica Lozier
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC
| | - Nichole T Tanner
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC; Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital, Charleston, SC
| | - Jessica S Wang Memoli
- Division of Pulmonary, Critical Care and Respiratory Services, Medstar Washington Hospital Center, Washington, DC
| | - Nicholas J Pastis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Gerard A Silvestri
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC.
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Mankidy BJ, Mohammad G, Trinh K, Ayyappan AP, Huang Q, Bujarski S, Jafferji MS, Ghanta R, Hanania AN, Lazarus DR. High risk lung nodule: A multidisciplinary approach to diagnosis and management. Respir Med 2023; 214:107277. [PMID: 37187432 DOI: 10.1016/j.rmed.2023.107277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.
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Affiliation(s)
- Babith J Mankidy
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
| | - GhasemiRad Mohammad
- Department of Radiology, Division of Vascular and Interventional Radiology, Baylor College of Medicine, USA.
| | - Kelly Trinh
- Texas Tech University Health Sciences Center, School of Medicine, USA.
| | - Anoop P Ayyappan
- Department of Radiology, Division of Thoracic Radiology, Baylor College of Medicine, USA.
| | - Quillan Huang
- Department of Oncology, Baylor College of Medicine, USA.
| | - Steven Bujarski
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
| | | | - Ravi Ghanta
- Department of Cardiothoracic Surgery, Baylor College of Medicine, USA.
| | | | - Donald R Lazarus
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
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Khan F, Seaman J, Hunter TD, Ribeiro D, Laxmanan B, Kalsekar I, Cumbo-Nacheli G. Diagnostic outcomes of robotic-assisted bronchoscopy for pulmonary lesions in a real-world multicenter community setting. BMC Pulm Med 2023; 23:161. [PMID: 37161376 PMCID: PMC10170714 DOI: 10.1186/s12890-023-02465-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Robot-assisted bronchoscopy (RAB) is among the newest bronchoscopic technologies, allowing improved visualization and access for small and hard-to-reach nodules. RAB studies have primarily been conducted at academic centers, limiting the generalizability of results to the broader real-world setting, while variability in diagnostic yield definitions has impaired the validity of cross-study comparisons. The objective of this study was to determine the diagnostic yield and sensitivity for malignancy of RAB in patients with pulmonary lesions in a community setting and explore the impact of different definitions on diagnostic yield estimates. METHODS Data were collected retrospectively from medical records of patients ≥ 21 years who underwent bronchoscopy with the Monarch® Platform (Auris Health, Inc., Redwood City, CA) for biopsy of pulmonary lesions at three US community hospitals between January 2019 and March 2020. Diagnostic yield was calculated at the index RAB and using 12-month follow-up data. At index, all malignant and benign (specific and non-specific) diagnoses were considered diagnostic. After 12 months, benign non-specific cases were considered diagnostic only when follow-up data corroborated the benign result. An alternative definition at index classified benign non-specific results as non-diagnostic, while an alternative 12-month definition categorized index non-diagnostic cases as diagnostic if no malignancy was diagnosed during follow-up. RESULTS The study included 264 patients. Median lesion size was 19.3 mm, 58.9% were peripherally located, and 30.1% had a bronchus sign. Samples were obtained via Monarch in 99.6% of patients. Pathology led to a malignant diagnosis in 115 patients (43.6%), a benign diagnosis in 110 (41.7%), and 39 (14.8%) non-diagnostic cases. Index diagnostic yield was 85.2% (95% CI: [80.9%, 89.5%]) and the 12-month diagnostic yield was 79.4% (95% CI: [74.4%, 84.3%]). Alternative definitions resulted in diagnostic yield estimates of 58.7% (95% CI: [52.8%, 64.7%]) at index and 89.0% (95% CI: [85.1%, 92.8%]) at 12 months. Sensitivity for malignancy was 79.3% (95% CI: [72.7%, 85.9%]) and cancer prevalence was 58.0% after 12 months. CONCLUSIONS RAB demonstrated a high diagnostic yield in the largest study to date, despite representing a real-world community population with a relatively low prevalence of cancer. Alternative definitions had a considerable impact on diagnostic yield estimates.
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Affiliation(s)
- Faisal Khan
- Franciscan Health Indianapolis, Indianapolis, IN, USA
| | - Joseph Seaman
- Sarasota Memorial Health Care System, Sarasota, FL, USA
| | - Tina D Hunter
- CTI Clinical Trial and Consulting Services, Covington, KY, 41011, USA.
| | - Diogo Ribeiro
- CTI Clinical Trial and Consulting Services, Covington, KY, 41011, USA
| | - Balaji Laxmanan
- Lung Cancer Initiative, Johnson & Johnson, New Brunswick, NJ, USA
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31
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Wook Kim Y, Kim HJ, Hyun Yoon S, Jin Song M, Soo Kwon B, Yoon Lim S, Joo Lee Y, Sun Park J, Cho YJ, Ho Lee J, Lee CT. Comparison of electromagnetic navigation bronchoscopy and transthoracic needle biopsy for diagnosing bronchus sign-positive pulmonary lesions. Lung Cancer 2023; 181:107234. [PMID: 37210790 DOI: 10.1016/j.lungcan.2023.107234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/15/2023] [Accepted: 05/06/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES Electromagnetic navigation bronchoscopy (ENB) is an advanced technique for diagnosing peripheral pulmonary lesions, and the bronchus sign is a well-established factor for improving the diagnostic performance. However, ENB is a novel technology compared to the commonly adopted transthoracic needle biopsy (TTNB). There are limited data on the comparison of these techniques for diagnosing bronchus sign-positive lesions. Therefore, we aimed to compare the diagnostic yield and complication rates of ENB and TTNB for diagnosing lung cancer in bronchus sign-positive pulmonary lesions. MATERIALS AND METHODS We assessed 2,258 individuals who underwent either of the techniques for initial biopsy between September 2016 and May 2022 at a tertiary center in South Korea and analyzed 1,248 participants (153 ENB and 1,095 TTNB cases) with a positive bronchus sign. We performed multivariable logistic regression analyses to evaluate the factors associated with the diagnostic yield, sensitivity for malignancy, and procedure-related complications. In addition, the outcomes were compared between the two techniques after a 1:2 propensity score-matching to control for pre-procedural factors. RESULTS After adjustments for clinical/radiological factors, performing TTNB over ENB was not significantly associated with a higher diagnostic yield but with a higher risk of pneumothorax (OR = 9.69, 95% CI = 4.15-22.59). Propensity score-matching resulted in 459 participants (153 ENB and 306 TTNB cases) with balanced pre-procedural characteristics. The overall diagnostic yield did not differ significantly between ENB and TTNB (85.0% vs. 89.9%, p = 0.124). The diagnostic yield (86.7% vs. 90.3%, p = 0.280) and sensitivity for malignancy (85.3% vs. 88.8%, p = 0.361) were comparable among patients with a class 2 bronchus sign. However, TTNB demonstrated a significantly higher complication rate of pneumothorax (28.8% vs. 3.9%, p < 0.001) and pneumothorax requiring tube drainage (6.5% vs. 2.0%, p = 0.034) than ENB. CONCLUSION ENB demonstrated a diagnostic yield comparable with that of TTNB for diagnosing bronchus sign-positive peripheral pulmonary lesions with significantly lower complication rates.
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Affiliation(s)
- Yeon Wook Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Hyun Yoon
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Byoung Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Kops SEP, Heus P, Korevaar DA, Damen JAA, Idema DL, Verhoeven RLJ, Annema JT, Hooft L, van der Heijden EHFM. Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis. Lung Cancer 2023; 180:107196. [PMID: 37130440 DOI: 10.1016/j.lungcan.2023.107196] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Abstract
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.
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Affiliation(s)
- Stephan E P Kops
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Pauline Heus
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Johanna A A Damen
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Demy L Idema
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roel L J Verhoeven
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Duke JD, Reisenauer J. Robotic bronchoscopy: potential in diagnosing and treating lung cancer. Expert Rev Respir Med 2023; 17:213-221. [PMID: 36939545 DOI: 10.1080/17476348.2023.2192929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Lung cancer remains the deadliest form of cancer in the world. Screening through low-dose CT scans has shown improved detection of pulmonary nodules; however, with the introduction of robotic bronchoscopy, accessing and biopsying peripheral pulmonary nodules from the airway has expanded. Improved diagnostic yield through enhanced navigation has made robotic bronchoscopy an ideal diagnostic technology for many proceduralists. Studies have demonstrated that robotic bronchoscopes can reach further with improved maneuverability into the distal airways compared to conventional bronchoscopes. AREAS COVERED This review paper highlights the literature on the technological advancements associated with robotic bronchoscopy and the future directions the field of interventional pulmonary may utilize this modality for in the treatment of lung cancer. Referenced articles were included at the discretion of the authors after a database search of the particular technology discussed. EXPERT OPINION As the localization of target lesions continues to improve, robotic platforms that provide reach, stability, and accuracy paves the way for future research in endoluminal treatment for lung cancer. Future studies with intratumoral injection of chemotherapy and immunotherapy and ablation modalities are likely to come in the coming years.
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Affiliation(s)
- Jennifer D Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic Rochester, Rochester, MN, USA
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The Surgical Management of Lung Neuroendocrine Neoplasms. Cancers (Basel) 2023; 15:cancers15061695. [PMID: 36980581 PMCID: PMC10046489 DOI: 10.3390/cancers15061695] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma.
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Kim YW, Kim HJ, Yoon SH, Song MJ, Kwon BS, Lim SY, Lee YJ, Park JS, Cho YJ, Lee JH, Lee CT. Electromagnetic Navigation Bronchoscopy Versus Radial Endobronchial Ultrasound for Diagnosing Lung Cancer: A Propensity Score-Matched Analysis. Arch Bronconeumol 2023:S0300-2896(23)00098-4. [PMID: 37005148 DOI: 10.1016/j.arbres.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Electromagnetic navigation bronchoscopy (ENB) and radial endobronchial ultrasound (R-EBUS) are advanced imaging-guided bronchoscopy techniques for diagnosing pulmonary lesions. This study aimed to determine the comparative diagnostic yield of sole ENB and R-EBUS under moderate sedation. METHODS We investigated 288 patients who underwent sole ENB (n=157) or sole R-EBUS (n=131) under moderate sedation for pulmonary lesion biopsy between January 2017 and April 2022. After a 1:1 propensity score-matching to control for pre-procedural factors, the diagnostic yield, sensitivity for malignancy, and procedure-related complications between both techniques were compared. RESULTS The matching resulted in 105 pairs/procedure for analyses with balanced clinical and radiological characteristics. The overall diagnostic yield was significantly higher for ENB than for R-EBUS (83.8% vs. 70.5%, p=0.021). ENB demonstrated a significantly higher diagnostic yield than R-EBUS among those with lesions>20mm in size (85.2% vs. 72.3%, p=0.034), radiologically solid lesions (86.7% vs. 72.7%, p=0.015), and lesions with a class 2 bronchus sign (91.2% vs. 72.3%, p=0.002), respectively. The sensitivity for malignancy was also higher for ENB than for R-EBUS (81.3% vs. 55.1%, p<0.001). After adjusting for clinical/radiological factors in the unmatched cohort, using ENB over R-EBUS was significantly associated with a higher diagnostic yield (odd ratio=3.45, 95% confidence interval=1.75-6.82). Complication rates for pneumothorax did not significantly differ between ENB and R-EBUS. CONCLUSION ENB demonstrated a higher diagnostic yield than R-EBUS under moderate sedation for diagnosing pulmonary lesions, with similar and generally low complication rates. Our data indicate the superiority of ENB over R-EBUS in a least-invasive setting.
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Hiddinga BI, Slebos DJ, David Koster T, Hijmering-Kappelle LBM, Hiltermann TJN, Kievit H, van der Wekken AJ, de Jonge G, Vliegenthart R, Van De Wauwer C, Timens W, Bensch F. The additional diagnostic value of virtual bronchoscopy navigation in patients with pulmonary nodules - The NAVIGATOR study. Lung Cancer 2023; 177:37-43. [PMID: 36708592 DOI: 10.1016/j.lungcan.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/15/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND The number of solitary pulmonary nodules to be evaluated is expected to increase and therefore we need to improve diagnostic and therapeutic tools to approach these nodules. To prevent patients from futile invasive procedures and receiving treatment without histological confirmation of cancer, we evaluated the value of virtual bronchoscopy navigation to obtain a diagnosis of the solitary pulmonary nodule in a real-world clinical setting. METHODS In the NAVIGATOR single center, prospective, observational cohort study patients underwent a virtual bronchoscopy navigation procedure with or without guide sheet tunnelling to assess a solitary pulmonary nodule. Nodules were considered not accessible if a diagnosis could not be obtained by either by CT-guided transthoracic biopsy or conventional bronchoscopy. RESULTS Between February 2021 and January 2022 35 patients underwent the virtual bronchoscopy navigation procedure. The overall diagnostic yield was 77% and was dependent on size of the nodule and chosen path, with highest yield in lesions with an airway path. Adverse events were few and manageable. CONCLUSION Virtual bronchoscopy navigation with or without sheet tunnelling is a new technique with a good diagnostic yield, also in patients in whom previously performed procedures failed to establish a diagnosis and/or alternative procedures are considered not feasible based on expected yield and/or safety. Preventing futile or more invasive procedures like surgery or transthoracic punctures with a higher complication rate is beneficial for patients, and allowed treatment adaptation in two-third of the analyzed patient population.
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Affiliation(s)
- Birgitta I Hiddinga
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Dirk-Jan Slebos
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - T David Koster
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Lucie B M Hijmering-Kappelle
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - T Jeroen N Hiltermann
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Hanneke Kievit
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Anthonie J van der Wekken
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gonda de Jonge
- Department of Radiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Caroline Van De Wauwer
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Wim Timens
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Frederike Bensch
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, the Netherlands
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Schwalk A, Styrvoky K. Longitudinal use of three different navigational bronchoscopy systems to sample lung nodules in a single patient. Respir Med Case Rep 2023; 43:101855. [PMID: 37138799 PMCID: PMC10149411 DOI: 10.1016/j.rmcr.2023.101855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023] Open
Abstract
Bronchoscopic techniques to sample suspicious lung nodules have progressed from traditional bronchoscopy to guided navigational bronchoscopy systems. Here we present the case of a patient who underwent navigational bronchoscopies using three different systems over a period of 41 months that diagnosed two primary and one metastatic thoracic malignancy. As guided bronchoscopy systems for the diagnosis of lung nodules continue to advance, it is important to recognize that the full utilization of accessible tools and technologies combined with shared decision making may often lead to a successful procedure and accurate diagnosis.
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Affiliation(s)
| | - Kim Styrvoky
- Corresponding author. University of Texas Southwestern Medical Center, Division of Pulmonary and Critical Care Medicine, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
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Fluoroscopy: Vintage Car, the Opportunity Knocks. J Bronchology Interv Pulmonol 2023; 30:87-89. [PMID: 36597200 DOI: 10.1097/lbr.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Shape-Sensing Robotic-Assisted Bronchoscopy with Concurrent use of Radial Endobronchial Ultrasound and Cone Beam Computed Tomography in the Evaluation of Pulmonary Lesions. Lung 2022; 200:755-761. [PMID: 36369295 DOI: 10.1007/s00408-022-00590-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE Lung nodules are a common radiographic finding. Non-surgical biopsy is recommended in patients with moderate or high pretest probability for malignancy. Shape-sensing robotic-assisted bronchoscopy (ssRAB) combined with radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography (CBCT) is a new approach to sample pulmonary lesions. Limited data are available regarding the diagnostic accuracy of combined ssRAB with r-EBUS and CBCT. METHODS We conducted a retrospective analysis of the first 200 biopsy procedures of 209 lung lesions using ssRAB, r-EBUS, and CBCT at UT Southwestern Medical Center in Dallas, Texas. Outcomes were based on pathology interpretations of samples taken during ssRAB, clinical and radiographic follow-up, and/or additional sampling. RESULTS The mean largest lesion dimension was 22.6 ± 13.3 mm with a median of 19 mm (range 7 to 73 mm). The prevalence of malignancy in our data was 64.1%. The diagnostic accuracy of ssRAB combined with advanced imaging was 91.4% (CI 86.7-94.8%). Sensitivity was 87.3% (CI 80.5-92.4%) with a specificity of 98.7% (CI 92.8-100%). The negative and positive predictive values were 81.3% and 99.2%. The rate of non-diagnostic sampling was 11% (23/209 samples). The only complication was pneumothorax in 1% (2/200 procedures), with 0.5% requiring a chest tube. CONCLUSION Our results of the combined use of ssRAB with r-EBUS and CBCT to sample pulmonary lesions suggest a high diagnostic accuracy for malignant lesions with reasonably high sensitivity and negative predictive values. The procedure is safe with a low rate of complications.
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Low SW, Lentz RJ, Chen H, Katsis J, Aboudara MC, Whatley S, Paez R, Rickman OB, Maldonado F. Shape-Sensing Robotic-Assisted Bronchoscopy vs Digital Tomosynthesis-Corrected Electromagnetic Navigation Bronchoscopy: A Comparative Cohort Study of Diagnostic Performance. Chest 2022; 163:977-984. [PMID: 36441041 DOI: 10.1016/j.chest.2022.10.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Electromagnetic navigational bronchoscopy has been the dominant bronchoscopic technology for targeting small peripheral lesions and now includes digital tomosynthesis-electromagnetic navigational bronchoscopy (DT-ENB), allowing near-real-time intraprocedural nodule visualization. Shape-sensing robotic-assisted bronchoscopy (ssRAB), with improved catheter stability and articulation recently became available. Although the diagnostic performance of these two methods seems higher than that of legacy systems, data remain limited. We sought to compare the diagnostic yield of these two novel platforms after their introduction at our institution. RESEARCH QUESTION Does the diagnostic yield of ssRAB differ significantly from that of DT-ENB in patients undergoing biopsy of peripheral pulmonary lesions (PPLs)? STUDY DESIGN AND METHODS This retrospective comparative cohort study analyzed prospectively collected data on consecutive procedures performed with DT-ENB and ssRAB in their first 6 months of use at our institution. Biopsies were considered diagnostic if histopathologic analysis revealed malignancy or specific benign features that readily explained the presence of a PPL. Nonspecific inflammation, normal lung or airway, and atypia not diagnostic of malignancy were considered nondiagnostic. RESULTS SSRAB was used to biopsy 143 PPLs in 133 patients and DT-ENB was used to biopsy 197 PPLs in 170 patients. Diagnostic yield was 77% for ssRAB (110 of 143 PPLs) and 80% (158 of 197 PPLs) for DT-ENB (OR, 0.8; 95% CI, 0.5-1.4; P = .4). Median lesion diameters were 17 and 19 mm, respectively. No difference in diagnostic yield was found after adjustment for lesion size, bronchus sign, peripheral vs middle third location, and sex. Pneumothorax complicated 1.5% of ssRAB and 1.8% of DT-ENB procedures (P = .86). INTERPRETATION SSRAB and DT-ENB showed comparable diagnostic yields and safety profiles in this comparative cohort study.
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Affiliation(s)
- See-Wei Low
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James Katsis
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Rush University, Chicago, IL
| | - Matthew C Aboudara
- Division of Pulmonary and Critical Care, St. Luke's Health System, University of Missouri-Kansas City, Kansas City, MO
| | - Samuel Whatley
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Rafael Paez
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Otis B Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
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Lachkar S, Perrot L, Gervereau D, De Marchi M, Morisse Pradier H, Dantoing E, Piton N, Thiberville L, Guisier F, Salaün M. Radial-EBUS and virtual bronchoscopy planner for peripheral lung cancer diagnosis: How it became the first-line endoscopic procedure. Thorac Cancer 2022; 13:2854-2860. [PMID: 36054681 PMCID: PMC9575082 DOI: 10.1111/1759-7714.14629] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 01/05/2023] Open
Abstract
Background Various advanced bronchoscopy methods have been developed to reach peripheral lung lesions (PLL). In a large cohort, we aimed to assess a standardized procedure of first‐line radial‐endobronchial ultrasound (r‐EBUS) and virtual bronchoscopy planner for the diagnosis of peripheral lung cancer. Methods This retrospective, single center study included patients who had r‐EBUS‐guided bronchoscopy for the diagnosis of a PLL between 2008 and 2019. Cases without a final diagnosis of cancer or follow‐up were excluded. Results Between 2008 and 2019, 2735 patients had a r‐EBUS procedure, among whom 1627 had a final diagnosis of cancer and were included in the present study. Over the 12‐year study period, r‐EBUS became the first‐line endoscopic procedure to assess PLL (25% as first‐line bronchoscopy in 2008 vs. 92% in 2019). The frequency of the bronchus sign decreased from 2009 to 2019 (100% to 80%; p = 0.001), whereas US visualization of the lesion remained stable (88%). The median number of biopsies increased from two (2008 to 2014) to four (2015 to 2019) (p < 0.0001), with the same diagnostic efficiency (74% total and 80% when a bronchus sign was present). Of the 651 adenocarcinomas, molecular analysis was possible in 86%. PD‐L1 expression analysis was possible in 81% of cases. During the study period, the lifetime of the radial probe increased from 57 procedures to 77 procedures/probe. Conclusion Because r‐EBUS and VB planner is easy to perform under local anesthesia, inexpensive and efficient it can be used as a first‐line procedure to assess peripheral lung cancer.
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Affiliation(s)
- Samy Lachkar
- Department of Pneumology, CHU Rouen, Rouen, France
| | - Loic Perrot
- Department of Pneumology, CHU Rouen, Rouen, France
| | | | | | | | | | - Nicolas Piton
- Department of Pathology, CHU Rouen, Rouen, France.,France and Normandie University, UNIROUEN, Inserm U1245, Rouen University Hospital, Rouen, France
| | - Luc Thiberville
- Department of Pneumology and Inserm CIC-CRB, Normandie Univ, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU Rouen, Rouen, France
| | - Florian Guisier
- Department of Pneumology and Inserm CIC-CRB, Normandie Univ, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU Rouen, Rouen, France
| | - Mathieu Salaün
- Department of Pneumology and Inserm CIC-CRB, Normandie Univ, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU Rouen, Rouen, France
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Folch E, Guo Y, Senitko M. Therapeutic Bronchoscopy for Lung Nodules: Where Are We Now? Semin Respir Crit Care Med 2022; 43:480-491. [PMID: 36104025 DOI: 10.1055/s-0042-1749368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Lobar resection has been the established standard of care for peripheral early-stage non-small cell lung cancer (NSCLC). Over the last few years, surgical lung sparing approach (sublobar resection [SLR]) has been compared with lobar resection in T1N0 NSCLC. Three nonsurgical options are available in those patients who have a prohibitive surgical risk, and those who refuse surgery: stereotactic body radiotherapy (SBRT), percutaneous ablation, and bronchoscopic ablation. Local ablation involves placement of a probe into a tumor, and subsequent application of either heat or cold energy, pulsing electrical fields, or placement of radioactive source under an image guidance to create a zone of cell death that encompasses the targeted lesion and an ablation margin. Despite being in their infancy, the bronchoscopic ablative techniques are undergoing rapid research, as they extrapolate a significant knowledge-base from the percutaneous techniques that have been in the radiologist's armamentarium since 2000. Here, we discuss selected endoscopic and percutaneous thermal and non-thermal therapies with the focus on their efficacy and safety.
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Affiliation(s)
- Erik Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yanglin Guo
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Michal Senitko
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, Mississippi.,Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
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Stone E, Leong TL. Contemporary Concise Review 2021: Pulmonary nodules from detection to intervention. Respirology 2022; 27:776-785. [PMID: 35581532 DOI: 10.1111/resp.14296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 12/11/2022]
Abstract
The US Preventive Task Force (USPSTF) has updated screening criteria by expanding age range and reducing smoking history required for eligibility; the International Lung Screen Trial (ILST) data have shown that PLCOM2012 performs better for eligibility than USPSTF criteria. Screening adherence is low (4%-6% of potential eligible candidates in the United States) and depends upon multiple system and patient/candidate-related factors. Smoking cessation in lung cancer improves survival (past prospective trial data, updated meta-analysis data); smoking cessation is an essential component of lung cancer screening. Circulating biomarkers are emerging to optimize screening and early diagnosis. COVID-19 continues to affect lung cancer treatment and screening through delays and disruptions; specific operational challenges need to be met. Over 70% of suspected malignant lesions develop in the periphery of the lungs. Bronchoscopic navigational techniques have been steadily improving to allow greater accuracy with target lesion approximation and therefore diagnostic yield. Fibre-based imaging techniques provide real-time microscopic tumour visualization, with potential diagnostic benefits. With significant advances in peripheral lung cancer localization, bronchoscopically delivered ablative therapies are an emerging field in limited stage primary and oligometastatic disease. In advanced stage lung cancer, small-volume samples acquired through bronchoscopic techniques yield material of sufficient quantity and quality to support clinically relevant biomarker assessment.
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Affiliation(s)
- Emily Stone
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tracy L Leong
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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