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Abdelghani R, Omballi M, Abia-Trujillo D, Casillas E, Villalobos R, Badar F, Bansal S, Kheir F. Imaging modalities during navigational bronchoscopy. Expert Rev Respir Med 2024; 18:175-188. [PMID: 38794918 DOI: 10.1080/17476348.2024.2359601] [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: 10/21/2023] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Lung nodules are commonly encountered in clinical practice. Technological advances in navigational bronchoscopy and imaging modalities have led to paradigm shift from nodule screening or follow-up to early lung cancer detection. This is due to improved nodule localization and biopsy confirmation with combined modalities of navigational platforms and imaging tools. To conduct this article, relevant literature was reviewed via PubMed from January 2014 until January 2024. AREAS COVERED This article highlights the literature on different imaging modalities combined with commonly used navigational platforms for diagnosis of peripheral lung nodules. Current limitations and future perspectives of imaging modalities will be discussed. EXPERT OPINION The development of navigational platforms improved localization of targets. However, published diagnostic yield remains lower compared to percutaneous-guided biopsy. The discordance between the actual location of lung nodule during the procedure and preprocedural CT chest is the main factor impacting accurate biopsies. The utilization of advanced imaging tools with navigation-based bronchoscopy has been shown to assist with localizing targets in real-time and improving biopsy success. However, it is important for interventional bronchoscopists to understand the strengths and limitations of these advanced imaging technologies.
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Affiliation(s)
- Ramsy Abdelghani
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, LA, USA
| | - Mohamed Omballi
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Casillas
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Regina Villalobos
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faraz Badar
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
| | - Sandeep Bansal
- The Lung Center, Penn Highlands Healthcare, DuBois, PA, USA
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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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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Chambers J, Knox D, Leclair T. O-arm CT for Confirmation of Successful Navigation During Robotic Assisted Bronchoscopy. J Bronchology Interv Pulmonol 2023; 30:155-162. [PMID: 36066326 PMCID: PMC10063183 DOI: 10.1097/lbr.0000000000000894] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Robotic assisted bronchoscopy (RAB) is designed to increase bronchoscopic accessibility for difficult to reach pulmonary lesions. One limitation to success of RAB is computed tomography (CT) to body divergence. Real time imaging with cone beam CT is increasingly utilized for confirmation of correct navigation and tool-in-lesion during RAB. O-arm CT is a 3-dimensional imaging modality, which has not previously been described for use with RAB. Our purpose is to display the feasibility, ease of use, and high rate of confirmation of tool-in-lesion when using O-arm CT during RAB. METHODS Single center, retrospective review of 75 patients undergoing RAB with intraprocedural use of O-arm CT. RESULTS Median patient age was 65 years. Forty-nine percent of cases involved nodules ≤2 cm. Bronchus sign was absent in 44% of cases. Median procedure time was 80 minutes. Median number of O-arm CT runs per case was 2. The median effective dose of radiation was 7.2 millisieverts. Tool-in-lesion was confirmed in 97% (77 of 79) of cases. Definitive diagnosis was reached in 61 to 68 of 79 cases (77% to 86%). There were 2 cases of pneumothorax (2.5%), one of which needed intervention with tube thoracostomy. CONCLUSIONS O-arm CT is an effective, and convenient alternative to other 3-dimensional imaging modalities for intraprocedural confirmation of tool-in-lesion during RAB.
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Affiliation(s)
- Jefferson Chambers
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Daniel Knox
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Timothy Leclair
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
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Advanced Imaging for Robotic Bronchoscopy: A Review. Diagnostics (Basel) 2023; 13:diagnostics13050990. [PMID: 36900134 PMCID: PMC10001114 DOI: 10.3390/diagnostics13050990] [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: 02/10/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Recent advances in navigational platforms have led bronchoscopists to make major strides in diagnostic interventions for pulmonary parenchymal lesions. Over the last decade, multiple platforms including electromagnetic navigation and robotic bronchoscopy have allowed bronchoscopists to safely navigate farther into the lung parenchyma with increased stability and accuracy. Limitations persist, even with these newer technologies, in achieving a similar or higher diagnostic yield when compared to the transthoracic computed tomography (CT) guided needle approach. One of the major limitations to this effect is due to CT-to-body divergence. Real-time feedback that better defines the tool-lesion relationship is vital and can be obtained with additional imaging using radial endobronchial ultrasound, C-arm based tomosynthesis, cone-beam CT (fixed or mobile), and O-arm CT. Herein, we describe the role of this adjunct imaging with robotic bronchoscopy for diagnostic purposes, describe potential strategies to counteract the CT-to-body divergence phenomenon, and address the potential role of advanced imaging for lung tumor ablation.
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Salahuddin M, Bashour SI, Khan A, Chintalapani G, Kleinszig G, Casal RF. Mobile Cone-Beam CT-Assisted Bronchoscopy for Peripheral Lung Lesions. Diagnostics (Basel) 2023; 13:diagnostics13050827. [PMID: 36899971 PMCID: PMC10000788 DOI: 10.3390/diagnostics13050827] [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: 01/30/2023] [Revised: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
Peripheral bronchoscopy with the use of thin/ultrathin bronchoscopes and radial-probe endobronchial ultrasound (RP-EBUS) has been associated with a fair diagnostic yield. Mobile cone-beam CT (m-CBCT) could potentially improve the performance of these readily available technologies. We retrospectively reviewed the records of patients undergoing bronchoscopy for peripheral lung lesions with thin/ultrathin scope, RP-EBUS, and m-CBCT guidance. We studied the performance (diagnostic yield and sensitivity for malignancy) and safety (complications, radiation exposure) of this combined approach. A total of 51 patients were studied. The mean target size was 2.6 cm (SD, 1.3 cm) and the mean distance to the pleura was 1.5 cm (SD, 1.4 cm). The diagnostic yield was 78.4% (95 CI, 67.1-89.7%), and the sensitivity for malignancy was 77.4% (95 CI, 62.7-92.1%). The only complication was one pneumothorax. The median fluoroscopy time was 11.2 min (range, 2.9-42.1) and the median number of CT spins was 1 (range, 1-5). The mean Dose Area Product from the total exposure was 41.92 Gy·cm2 (SD, 11.35 Gy·cm2). Mobile CBCT guidance may increase the performance of thin/ultrathin bronchoscopy for peripheral lung lesions in a safe manner. Further prospective studies are needed to corroborate these findings.
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Affiliation(s)
- Moiz Salahuddin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sami I. Bashour
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Asad Khan
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | | | - Roberto F. Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence:
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Chan JWY, Siu ICH, Chang ATC, Li MSC, Lau RWH, Mok TSK, Ng CSH. Transbronchial Techniques for Lung Cancer Treatment: Where Are We Now? Cancers (Basel) 2023; 15:cancers15041068. [PMID: 36831411 PMCID: PMC9954491 DOI: 10.3390/cancers15041068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/29/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
The demand for parenchyma-sparing local therapies for lung cancer is rising owing to an increasing incidence of multifocal lung cancers and patients who are unfit for surgery. With the latest evidence of the efficacy of lung cancer screening, more premalignant or early-stage lung cancers are being discovered and the paradigm has shifted from treatment to prevention. Transbronchial therapy is an important armamentarium in the local treatment of lung cancers, with microwave ablation being the most promising based on early to midterm results. Adjuncts to improve transbronchial ablation efficiency and accuracy include mobile C-arm platforms, software to correct for the CT-to-body divergence, metal-containing nanoparticles, and robotic bronchoscopy. Other forms of energy including steam vapor therapy and pulse electric field are under intensive investigation.
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Affiliation(s)
- Joyce W. Y. Chan
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ivan C. H. Siu
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Aliss T. C. Chang
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Molly S. C. Li
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rainbow W. H. Lau
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tony S. K. Mok
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Calvin S. H. Ng
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
- Correspondence:
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Xia Y, Li Q, Zhong C, Wang K, Li S. Inheritance and innovation of the diagnosis of peripheral pulmonary lesions. Ther Adv Chronic Dis 2023; 14:20406223221146723. [PMID: 36743297 PMCID: PMC9896091 DOI: 10.1177/20406223221146723] [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: 07/20/2022] [Accepted: 12/05/2022] [Indexed: 01/29/2023] Open
Abstract
As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.
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The Road to 90. J Bronchology Interv Pulmonol 2023; 30:89-91. [PMID: 36597201 DOI: 10.1097/lbr.0000000000000862] [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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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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The Feasibility of Using the "Artery Sign" for Pre-Procedural Planning in Navigational Bronchoscopy for Parenchymal Pulmonary Lesion Sampling. Diagnostics (Basel) 2022; 12:diagnostics12123059. [PMID: 36553068 PMCID: PMC9777140 DOI: 10.3390/diagnostics12123059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) and robotic-assisted bronchoscopy (RAB) systems are used for pulmonary lesion sampling, and utilize a pre-procedural CT scan where an airway, or "bronchus sign", is used to map a pathway to the target lesion. However, up to 40% of pre-procedural CT's lack a "bronchus sign" partially due to surrounding emphysema or limitation in CT resolution. Recognizing that the branches of the pulmonary artery, lymphatics, and airways are often present together as the bronchovascular bundle, we postulate that a branch of the pulmonary artery ("artery sign") could be used for pathway mapping during navigation bronchoscopy when a "bronchus sign" is absent. Herein we describe the navigation success and safety of using the "artery sign" to create a pathway for pulmonary lesion sampling. METHODS We reviewed data on consecutive cases in which the "artery sign" was used for pre-procedural planning for conventional ENB (superDimension™, Medtronic) and RAB (Monarch™, Johnson & Johnson). Patients who underwent these procedures from July 2020 until July 2021 at the University of Minnesota Medical Center and from June 2018 until December 2019 at the University of Chicago Medical Center were included in this analysis (IRB #19-0011 for the University of Chicago and IRB #00013135 for the University of Minnesota). The primary outcome was navigation success, defined as successfully maneuvering the bronchoscope to the target lesion based on feedback from the navigation system. Secondary outcomes included navigation success based on radial EBUS imaging, pneumothorax, and bleeding rates. RESULTS A total of 30 patients were enrolled in this analysis. The median diameter of the lesions was 17 mm. The median distance of the lesion from the pleura was 5 mm. Eleven lesions were solid, 15 were pure ground glass, and 4 were mixed. All cases were planned successfully using the "artery sign" on either the superDimension™ ENB (n = 15) or the Monarch™ RAB (n = 15). Navigation to the target was successful for 29 lesions (96.7%) based on feedback from the navigation system (virtual target). Radial EBUS image was acquired in 27 cases (90%) [eccentric view in 13 (43.33%) and concentric view in 14 patients (46.66%)], while in 3 cases (10%) no r-EBUS view was obtained. Pneumothorax occurred in one case (3%). Significant airway bleeding was reported in one case (3%). CONCLUSIONS We describe the concept of using the "artery sign" as an alternative for planning EMN and RAB procedures when "bronchus sign" is absent. The navigation success based on virtual target or r-EBUS imaging is high and safety of sampling of such lesions compares favorably with prior reports. Prospective studies are needed to assess the impact of the "artery sign" on diagnostic yield.
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