Cone-beam CT and Augmented Fluoroscopy-guided Navigation Bronchoscopy: Radiation Exposure and Diagnostic Accuracy Learning Curves

Pulmonary endoscopy - central to an interventional pulmonology program

INTRODUCTION

Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options.

AREAS COVERED

This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques.

EXPERT OPINION

EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Feasibility and Impact on Diagnosis of Peripheral Pulmonary Lesions under Real-Time Direct Vision by Iriscope®

INTRODUCTION

Interventional pneumology plays a crucial role in the diagnosis of peripheral pulmonary lesions (PPLs), offering a minimally invasive approach with a low risk of complications. Iriscope® is a novel device that provides a direct and real-time image of PPLs. The objective of this study was to demonstrate the feasibility and impact of Iriscope® in diagnosing PPLs by analyzing its ability to directly visualize lesions and support accurate sampling during radial probe endobronchial ultrasound (rEBUS) and electromagnetic navigation bronchoscopy (ENB) combined with rEBUS.

METHODS

A single-center prospective study was conducted from December 2022 to October 2023 on patients with suspicious PPLs. The diagnostic approach involved either rEBUS alone or in combination with ENB. In all cases, an additional novel technique called Iriscope® (Lys Medical, Charleroi, Belgium) was also applied. Iriscope® findings of each lesion were evaluated individually by three expert interventional pulmonologists.

RESULTS

Seventy PPLs suspected of malignancy were included in the study. The PPLs underwent examination by ENB combined with rEBUS (55) or by rEBUS alone (15). Diagnosis was obtained in 68.6% (48/70) of cases. Iriscope® provided a direct, real-time view of 57.1% (40/70) of PPLs with a positive predictive value of 92.5% (37/40). This technique was able to visualize 72% (39/54) of malignant lesions, while only 6.1% (1/16) of benign lesions showed pathologic changes. The most common findings observed with Iriscope® were mucosal thickening and infiltration (92.5%), increased capillary vascularization (82%), pale or grayish mucosa (72.5%), obstruction with accumulation of secretions (50%), and cobblestone mucosa (15%).

CONCLUSION

Iriscope® is a promising technique in the diagnostic process of PPLs, providing real-time pathologic imaging that facilitates accurate sampling. Further studies are needed to evaluate success rate of Iriscope-mediated repositioning and to establish predictive patterns for malignant or even benign diseases.

Cone-beam computed tomography-guided shape-sensing robotic bronchoscopy vs. electromagnetic navigation bronchoscopy for pulmonary nodules

Background

Electromagnetic navigation bronchoscopy (ENB) and shape-sensing robotic-assisted bronchoscopy (ssRAB) are minimally invasive technologies for the diagnosis of pulmonary nodules. Cone-beam computed tomography (CBCT) has shown to increase diagnostic yield by allowing real-time confirmation of position of lesion and biopsy tool. There is a lack of comparative studies of such platforms using CBCT guidance to overcome computed tomography to body divergence. The aim of this study was to compare the diagnostic yield of ENB- and ssRAB-guided CBCT for biopsy of pulmonary nodules.

Methods

We conducted a retrospective comparative study of consecutive patients undergoing ENB-CBCT and ssRAB-CBCT. Navigational success was defined as biopsy tool within lesion confirmed during CBCT. Diagnostic yield was assessed using two methods: (I) presence of malignancy or benign histological findings that lead to a specific diagnosis at the time of bronchoscopy, and (II) longitudinal follow-up of patients with nonspecific benign finding during bronchoscopy.

Results

ENB-CBCT was used to biopsy 97 nodules and ssRAB-CBCT was used to biopsy 111 nodules. Median size of the lesion for the ENB-CBCT group was 16.5 mm [interquartile range (IQR), 12-22 mm] as compared to 12 mm (IQR, 9-16 mm) in the ssRAB-CBCT group (P<0.001). Navigational success was 70.1% in ENB-CBCT arm as compared to 83% in ssRAB-CBCT arm respectively (P=0.03). Diagnostic yield was 66% for ENB-CBCT and 89.2% for ssRAB-CBCT (P<0.001) following bronchoscopy; 79.4% for ENB-CBCT and 95.4% for ssRAB-CBCT (P<0.001) with longitudinal follow-up data respectively. Following multivariate regression analysis adjusting for the size of the lesion, distance from the pleura, presence of bronchus sign, number of CBCT spins, and number of nodules, the odds ratio for the diagnostic yield was 4.72 [95% confidence interval (CI): 2.05-10.85; P<0.001] in the ssRAB-CBCT group as compared with ENB-CBCT. The overall rate of adverse events was similar in both groups (P=0.77).

Conclusions

ssRAB-CBCT showed increased navigational success and diagnostic yield as compared to ENB-CBCT for pulmonary nodule biopsies.

Cone Beam Computed Tomography-Guided Navigation Bronchoscopy with Augmented Fluoroscopy for the Diagnosis of Peripheral Pulmonary Nodules: A Step-by-Step Guide

INTRODUCTION

Cone beam computed tomography-guided navigation bronchoscopy (CBCT-NB) with augmented fluoroscopy (AF) guidance represents a minimally invasive endobronchial technique for diagnosing small, peripheral pulmonary lesions. This approach is characterized by its high diagnostic accuracy and low complication risk. Current pilot trials are exploring the application of localized therapies using this innovative approach. This report aims to provide a detailed procedural guide for performing CBCT-NB with AF guidance as the only tool for navigation and image guided biopsy.

METHODS

We outline the procedural steps involved in the CBCT-NB procedure for diagnosing peripheral pulmonary lesions, supported by specific intra-procedural clinical video footage. The steps include (1) preprocedural considerations, (2) a detailed procedural workflow encompassing navigation to the target lesion, (3) position confirmation and tissue acquisition, and (4) postprocedural follow-up.

CONCLUSION

CBCT-NB with AF guidance is a safe and precise stand-alone navigation modality that offers high-resolution real-time 3D imaging, enhancing the diagnosis and potential treatment of peripheral pulmonary nodules.

Determinants of radiation exposure during mobile cone-beam CT-guided robotic-assisted bronchoscopy

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.

Advanced Diagnostic and Therapeutic Bronchoscopy in Pediatrics

Advanced diagnostic and therapeutic flexible bronchoscopy in children is a rapidly evolving field. Recent advances in technology and awareness of indications, risks, and benefits by pediatric providers have greatly increased the use of advanced techniques in children. This review highlights advanced diagnostic procedures including assessment of endobronchial lesions, mediastinal/hilar masses, and peripheral lung nodules as well as therapeutic techniques for restoring airway lumen patency, managing persistent air leaks, and treating tracheoesophageal fistulas in children as well as the potential to spare these patients more invasive procedures.

State of the art: peripheral diagnostic bronchoscopy

Lung cancer is the leading cause of cancer related death worldwide and in the United States according to the World Health Organization and National Cancer Institute. Improvements in the diagnosis and treatment of lung cancer are of the utmost importance. A prompt diagnosis is a crucial factor to improve outcomes in the treatment of lung cancer. Although the implementation of lung cancer screening guidelines and the overall steady growth in the use of computed tomography have improved the likelihood of detecting lung cancer at an earlier stage, the diagnosis of peripheral pulmonary lesions (PPLs) has remained a challenge. The bronchoscopic techniques for PPL sampling have historically offered modest diagnostic yields at best in comparison to computed tomography guided transthoracic needle aspiration (TTNA). Fortunately, recent advances in technology have ushered in a new era of diagnostic peripheral bronchoscopy. In this review, we discuss the introduction of advanced intraprocedural imaging included digital tomosynthesis (DT), augmented fluoroscopy (AF), and cone beam computed tomography. We discuss robotic assisted bronchoscopy with a review of the currently available platforms, and we discuss the implementation of novel biopsy tools. These technologic advances in the bronchoscopic approach to PPLs offer greater diagnostic certainty and pave the way toward peripheral therapeutics in bronchoscopy.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Radiation Principles, Protection, and Reporting for Interventional Pulmonology: A World Association of Bronchology and Interventional Pulmonology White Paper

The use and availability of diverse advanced X-ray based imaging and guidance systems in the field of interventional pulmonology are rapidly growing. This popularity links inextricably to an increase in ionizing radiation use. Knowing ionizing radiation is hazardous, knowledge and competent use of X-ray imaging and guidance systems are important. The globally implemented As Low As Reasonably Achievable (ALARA) principle demands careful attention to minimize radiation exposure while achieving the precise goals of the intervention and imaging therein. To allow careful and targeted weighing of risk against reward while using X-ray based equipment, proper background knowledge of physics as well as imaging system aspects are needed. This white paper summarizes the principles of ionizing radiation which are crucial to enhance awareness and interpretation of dosimetric quantities. Consecutively, a consensus on standards for reporting radiation exposure in interventional pulmonology procedures is indicated to facilitate comparisons between different systems, approaches and results. Last but not least, it provides a list of practical measures, considerations and tips to optimize procedural imaging as well as reduce radiation dose to patients and staff.

Added Value of a Robotic-assisted Bronchoscopy Platform in Cone Beam Computed Tomography-guided Bronchoscopy for the Diagnosis of Pulmonary Parenchymal Lesions

BACKGROUND

Cone beam computed tomography (CBCT)-guided bronchoscopic sampling of peripheral pulmonary lesions (PPLs) is associated with superior diagnostic outcomes. However, the added value of a robotic-assisted bronchoscopy platform in CBCT-guided diagnostic procedures is unknown.

METHODS

We performed a retrospective review of 100 consecutive PPLs sampled using conventional flexible bronchoscopy under CBCT guidance (FB-CBCT) and 100 consecutive PPLs sampled using an electromagnetic navigation-guided robotic-assisted bronchoscopy platform under CBCT guidance (RB-CBCT). Patient demographics, PPL features, procedural characteristics, and procedural outcomes were compared between the 2 cohorts.

RESULTS

Patient and PPL characteristics were similar between the FB-CBCT and RB-CBCT cohorts, and there were no significant differences in diagnostic yield (88% vs. 90% for RB-CBCT, P=0.822) or incidence of complications between the 2 groups. As compared with FB-CBCT cases, RB-CBCT cases were significantly shorter (median 58 min vs. 92 min, P<0.0001) and used significantly less diagnostic radiation (median dose area product 5114 µGy•m2 vs. 8755 µGy•m2, P<0.0001).

CONCLUSION

CBCT-guided bronchoscopy with or without a robotic-assisted bronchoscopy platform is a safe and effective method for sampling PPLs, although the integration of a robotic-assisted platform was associated with significantly shorter procedure times and significantly less radiation exposure.

Effective Radiation Dose from Cone-Beam Computed Tomography Guidance during Bronchoscopic Tumour Ablation

INTRODUCTION

Endobronchial radiofrequency ablation (RFA) is a novel minimally invasive approach to management of peripheral non-small-cell lung cancer (NSCLC) in medically inoperable patients. Minimally invasive ablative techniques are generally delivered with cone-beam computed tomography (CBCT) guidance. CBCT requires a significant number of two dimensional imaging projections to be acquired which is then reconstructed as a three-dimensional cone-beam image. The objective of this study was to determine the radiation dosimetry consequent to use of CBCT guidance for bronchoscopic RFA.

METHODS

Post hoc analysis of data following bronchoscopic RFA of stage I biopsy-confirmed NSCLC performed with CBCT. Effective dose estimates for these patients were calculated using PCXMC2.0 software.

RESULTS

Ten patients underwent bronchoscopic RFA, with a median 3 (range 2-4) CBCT spins per procedure. Mean dose area product (DAP) per procedure was 7,778 μGy.m2 (±4,743) with an effective dose of 11.6 mSv (±7.4). The DAP per spin for these 10 patients varied from 83.8 to 8,625.6 μGy.m2 (effective dose range 0.15-13.81 mSv).

CONCLUSION

This is the first study to report radiation dosimetry consequent to CT guidance for bronchoscopic RFA procedures. Effective doses appear comparable to other CT fluoroscopic procedures.

Feasibility of a Prototype Image Reconstruction Algorithm for Motion Correction in Interventional Cone-Beam CT Scans

RATIONALE AND OBJECTIVES

Assess the feasibility of a prototype image reconstruction algorithm in correcting motion artifacts in cone-beam computed tomography (CBCT) scans of interventional instruments in the lung.

MATERIALS AND METHODS

First, phantom experiments were performed to assess the algorithm, using the Xsight lung phantom with custom inserts containing straight or curved catheters. During scanning, the inserts moved in a continuous sinusoidal or breath-hold mimicking pattern, with varying amplitudes and frequencies. Subsequently, the algorithm was applied to CBCT data from navigation bronchoscopy procedures. The algorithm's performance was assessed quantitatively via edge-sharpness measurements and qualitatively by three specialists.

RESULTS

In the phantom study, the algorithm improved sharpness in 13 out of 14 continuous sinusoidal motion and five out of seven breath-hold mimicking scans, with more significant effects at larger motion amplitudes. Analysis of 27 clinical scans showed that the motion corrected reconstructions had significantly sharper edges than standard reconstructions (2.81 (2.24-6.46) vs. 2.80 (2.16-4.75), p = 0.003). These results were consistent with the qualitative assessment, which showed higher scores in the sharpness of bronchoscope-tissue interface and catheter-tissue interface in the motion-corrected reconstructions. However, the tumor demarcation ratings were inconsistent between raters, and the overall image quality of the new reconstructions was rated lower.

CONCLUSION

Our findings suggest that applying the new prototype algorithm for motion correction in CBCT images is feasible. The algorithm improved the sharpness of medical instruments in CBCT scans obtained during diagnostic navigation bronchoscopy procedures, which was demonstrated both quantitatively and qualitatively.

Cone-beam CT-based Navigation With Augmented Fluoroscopy of the Airways for Image-guided Bronchoscopic Biopsy of Peripheral Pulmonary Nodules: A Prospective Clinical Study

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.

A simple and safe surgical technique for nonpalpable lung tumors: One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH)

When performing thoracoscopic partial resections of nonpalpable lung tumors such as ground-glass opacities (GGOs) and small tumors, detecting the location of the lesion and assessing the resection margins can be challenging. We have developed a novel method to ease this difficulty, the One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH), which uses a hybrid operating room wherein the operating table is seamlessly integrated with cone-beam computed tomography (CBCT). We performed the OS-MRCH method on 62 nodules including primary lung cancer presenting with GGO. Identification of the lesion and confirmation of the margin were performed in 58 of the cases, while nodules were detected in all. The frequency of computed tomography (CT) scans performed prior to resection was one time in 51 cases, two times in eight cases, and ≥3 times in three cases. Additional resection was performed in two cases. The median operative time was 85.0 minutes, and the median pathological margin was 11.0 mm. The key advantages of this method are that all surgical processes can be completed in a single session, specialized skill sets are not required, and it is feasible to perform in any facility equipped with a hybrid operating room. To overcome its disadvantages, such as longer operating time and limited patient positioning, we devised various methods for positioning patients and for CT imaging of the resected specimens. OS-MRCH is a simple, useful, and practical method for performing thoracoscopic partial resection of nonpalpable lung tumors.

Imaging modalities during navigational bronchoscopy

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.

Imaging in peripheral bronchoscopy

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.

Procedural times with robotic-assisted bronchoscopy: a high volume single-center study

BACKGROUND

Incidental and screen-detected pulmonary nodules are common. The increasing capabilities of advanced diagnostic bronchoscopy will increase bronchoscopists' procedural volume necessitating optimization of procedural scheduling and workflow.

OBJECTIVES

The objectives of this study were to determine total time in the procedure room, total bronchoscopy procedure time, and robotic-assisted bronchoscopy procedure time longitudinally and per specific procedure performed.

DESIGN

A single-center observational study of all consecutive patients undergoing shape-sensing robotic-assisted bronchoscopy (RAB) biopsy procedures for the evaluation of pulmonary lesions with variable probability for malignancy.

METHODS

Chart review to collect patient demographics, lesion characteristics, and procedural specifics. Descriptive and comparative statistics are reported.

RESULTS

Actual bronchoscopy procedure time may decrease with increased institutional experience over time, however, there is limited ability to reduce non-bronchoscopy related time within the procedure room. The use of cone beam computed tomography (CBCT), rapid on-site evaluation (ROSE), and performance of staging endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) in a single procedure are each associated with additional time requirements.

CONCLUSION

Institutional procedural block times should adapt to the nature of advanced diagnostic bronchoscopy procedures to allow for the accommodation of new modalities such as RAB combined with other technologies including radial endobronchial ultrasound, CBCT, ROSE, and staging linear EBUS. Identifying institutional median procedural times may assist in scheduling and ideal block time utilization.

Radiation dose of cone beam CT combined with shape sensing robotic assisted bronchoscopy for the evaluation of pulmonary lesions: an observational single center study

Background

Shape sensing robotic-assisted bronchoscopy (ssRAB) combined with radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography (CBCT) is a newer diagnostic modality for the evaluation of pulmonary lesions. There is limited data describing the radiation dose of CBCT combined with ssRAB. The purpose of this study was to describe the technical factors associated with the use of CBCT combined with ssRAB to biopsy pulmonary lesions.

Methods

We conducted a single center, prospective observational study of patients undergoing ssRAB combined with fixed CBCT for the pulmonary lesion biopsy. We report our patient demographics, and pulmonary lesion and procedure characteristics.

Results

A total of 241 ssRAB procedures were performed to biopsy 269 pulmonary lesions. The mean lesion size was measured in the following dimensions: anteroposterior (18.0±8.8 mm), transverse (17.2±10.5 mm), and craniocaudal (17.7±10.2 mm). A mean of 1.5±0.7 (median: 1, range: 1-4) CBCT spins were performed. The mean total fluoroscopy time (FT) was 5.6±2.9 minutes. The mean radiation dose of cumulative air kerma (CAK) was 63.5±46.7 mGy and the mean cumulative dose area product (DAP) was 22.6±16.0 Gy·cm2. Diagnostic yield calculated based on results at index bronchoscopy was 85.9%. There was a low rate of complications with 8 pneumothoraces (3.3%), 5 (2.1%) of which required chest tube placement.

Conclusions

We describe the use of ssRAB combined with CBCT to biopsy pulmonary lesions as a safe diagnostic modality with relatively low radiation dose that is potentially comparable to other image guided sampling modalities. Bronchoscopists should be cognizant of the radiation use during the procedure for both patient and staff safety.

Cone-beam CT in lung biopsy: a clinical practice review on lessons learned and future perspectives

Pulmonary nodules with intermediate to high risk of malignancy should preferably be diagnosed with image guide minimally invasive diagnostics before treatment. Several technological innovations have been developed to endobronchially navigate to these lesions and obtain tissue for diagnosis. This review addresses these technological advancements in navigation bronchoscopy in three basic steps: navigation, position confirmation and acquisition, with a specific focus on cone-beam computed tomography (CBCT). For navigation purposes ultrathin bronchoscopy combined with virtual bronchoscopy navigation, electromagnetic navigation and robotic assisted bronchoscopy all achieve good results as a navigation guidance tool, but cannot confirm location or guide biopsy positioning. Diagnostic yield has seen improvement by combining these techniques with a secondary imaging tool like radial endobronchial ultrasound (rEBUS) and fluoroscopy. For confirmation of lesion access, rEBUS provides local detailed ultrasound-imaging and can be used to confirm lesion access in combination with fluoroscopy, measure nodule-contact area length and determine catheter position for sampling. CBCT is the only technology that can provide precise 3D positioning confirmation. When focusing on tissue acquisition, there is often more than 10% difference between reaching the target and getting a diagnosis. This discrepancy is multifactorial and caused by breathing movements, small samples sizes, instrument tip displacements by tool rigidity and tumour inhomogeneity. Yield can be improved by targeting fluorodeoxyglucose (FDG)-avid regions, immediate feedback of rapid onsite evaluation, choosing sampling tools with different passive stiffnesses, by increasing the number biopsies taken and (future) catheter modifications like (robotic assisted-) active steering. CBCT with augmented fluoroscopy (CBCT-AF) based navigation bronchoscopy combines navigation guidance with 3D-image confirmation of instrument-in-lesion positioning in one device. CBCT-AF allows for overlaying the lesion and navigation pathway and the possibility to outline trans-parenchymal pathways. It can help guide and verify sampling in 3D in near real-time. Disadvantages are the learning curve, the inherent use of radiation and limited availability/access to hybrid theatres. A mobile C-arm can provide 3D imaging, but lower image quality due to lower power and lower contrast-to-noise ratio is a limiting factor. In conclusion, a multi-modality approach in experienced hands seems the best option for achieving a diagnostic accuracy >85%. Either adequate case selection or detailed 3D imaging are essential to obtain high accuracy. For current and future transbronchial treatments, high-resolution (CBCT) 3D-imaging is essential.

Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement

BACKGROUND

Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes.

METHODS

A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes.

RESULTS

Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented.

CONCLUSION

This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.

High diagnostic yield of electromagnetic navigation bronchoscopy performed under cone beam CT guidance: results of a randomized Belgian monocentric study

BACKGROUND

With the increasing use of low dose CT scans, numerous pulmonary nodules are detected. As majority of them are benign, development of efficient non-surgical diagnostic intervention is mandatory. Electromagnetic navigation bronchoscopy (ENB) has been developed to reach difficult to access lesions. The aim of the present study was to compare the diagnostic yield of ENB procedures performed in a classical endoscopy suite or in a hybrid room equipped by a cone beam CT (CBCT).

METHODS

A monocentric randomized study was performed in the Erasme Hospital between January 2020 and December 2021. Lung nodules of maximum 30 mm of diameter were eligible. In both arms (endoscopy or CBCT suites), ENB, fluoroscopic guidance and a radial endobronchial ultrasound were used to reach the lesion. Then six trans-bronchial biopsies (TBB) and one trans-bronchial lung cryobiopsy (TBLC) were performed. Primary outcomes were the diagnostic yield and diagnostic accuracy of the procedure.

RESULTS

Forty-nine patients were randomized (24 in the endoscopy and 25 in the CBCT arms). The lesion size was 15,9 ± 4,6 mm and 16,6 ± 6,0 mm respectively (mean ± SD, p = NS). The diagnostic yield of ENB performed under CBCT guidance was 80% compared to 42% when performed in the endoscopy suite under standard fluoroscopic guidance (p < 0,05). Similarly, the diagnostic accuracy in the CBCT group was 87% compared to 54% for the endoscopy group (p < 0,05). Duration of the procedure in the CBCT and endoscopy arms was 80 ± 23 and 61 ± 13 min respectively (mean ± SD, p < 0,01). Performing TBLC in addition to TBB increased the diagnostic yield by 14% (17 and 12,5% in CBCT and endoscopy suites respectively, p = NS).

CONCLUSION

This study highlighted the additional value to perform ENB procedure under CBCT guidance for small size (less than 2 cm of diameter) pulmonary nodules.

TRIAL REGISTRATION

Clinical trial registration number: NCT05257382.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Learning Curve of Real-Time Imaging with C-Arm Based Tomography for Peripheral Lung Nodule Biopsy

The number of procedures required to attain proficiency with new bronchoscopic biopsy technologies for peripheral pulmonary lesions (PPLs) is uncertain. A prospective, single-center study evaluated learning curves of two operators performing PPL biopsies using a novel, real-time, intraoperative tomographic imaging system in consecutive procedures in adults with CT-detected PPLs. Operators were considered “proficient” when they asked three or fewer questions of the manufacturer’s clinical representative with no subsequent navigations in which they asked more than three questions. A total of 31 procedures were performed on 31 patients (Operator 1: 18, Operator 2: 13). Proficiency was achieved after an average of 10 procedures (Operator 1: 12, Operator 2: 8). From the learning curve to the post-learning curve period, the number of questions (median [IQR]: 23 [9.5–41.5] versus 0 [0–1], p < 0.001) and radiation dose (median [IQR]: 19.5 mGy/m2 [1.9–43.5] versus 1.5 mGy/m2 [0.7–3.3], p = 0.05) decreased significantly; procedure time decreased (median [IQR]: 12 min [7–20] versus 8 min [3–15], p = 0.29); and diagnostic yield increased significantly (13/20 cases [65%] to 11/11 cases [100%]), (p = 0.03). Based on this unique, clinically relevant method of assessing learning curve, proficiency with the Body Vision system was achieved at approximately the tenth procedure. These findings require validation in larger, diverse populations.

Cone-Beam Computed-Tomography-Derived Augmented Fluoroscopy-Guided Biopsy for Peripheral Pulmonary Nodules in a Hybrid Operating Room: A Case Series

Lung cancer is the most lethal cancer type in Taiwan and worldwide. Early detection and treatment advancements have improved survival. However, small peripheral pulmonary nodules (PPN) biopsy is often challenging, relying solely on bronchoscopy with radial endobronchial ultrasound (EBUS). Augmented fluoroscopy overlays the intra-procedural cone-beam computed tomography (CBCT) images with fluoroscopy enabling real-time three-dimensional localization during bronchoscopic transbronchial biopsy. The hybrid operating room (HOR), equipped with various types of C-arm CBCT, is a perfect suite for PPN diagnosis and other interventional pulmonology. This study shares the single institute experience of EBUS transbronchial biopsy of PPN with the aid of augmented fluoroscopic bronchoscopy (AFB) and CBCT in an HOR. We retrospectively enrolled patients who underwent robotic CBCT, augmented fluoroscopy-guided, radial endobronchial ultrasound-confirmed transbronchial biopsy and cryobiopsy in a hybrid operating room. Patient demographic characteristics, computed tomography images, rapid on-site evaluation cytology, and final pathology reports were collected. Forty-one patients underwent transbronchial biopsy and 6 received additional percutaneous transthoracic core-needle biopsy during the same procedure. The overall diagnostic yield was 88%. The complications included three patients with pneumothorax after receiving subsequent CT-guided percutaneous transthoracic needle biopsy, and two patients with hemothorax who underwent transbronchial cryobiopsy. Overall, the bronchoscopic biopsy of PPN using AFB and CBCT as precise guidance in the hybrid operating room is feasible and can be performed safely with a high diagnostic yield.

The additional diagnostic value of virtual bronchoscopy navigation in patients with pulmonary nodules - The NAVIGATOR study

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.

Cone-beam computed tomography-guided endobronchial ultrasound using an ultrathin bronchoscope for diagnosis of peripheral pulmonary lesions: a prospective pilot study

Background

Multimodal transbronchial biopsy (TBB) may have improved diagnostic yield for peripheral pulmonary lesions suspected as lung cancer. Radial endobronchial ultrasound (R-EBUS) provides real-time imaging and confirmation of the location of the lesions. Cone-beam computed tomography (CBCT) can confirm that the forceps tip has reached the lesion before biopsy.

Methods

Patients with peripheral pulmonary lesions and a positive computed tomography (CT) bronchus sign (based on slice thickness of 1 mm) were prospectively enrolled. An ultrathin bronchoscope (UTB) and R-EBUS probe were advanced to the target bronchus. Thereafter, forceps were advanced, and CBCT was performed. R-EBUS was performed for re-navigation, if possible. The obtained EBUS and CBCT images were classified into "within" (type 1), "adjacent to" (type 2), or "far from" (type 3), based on the probe or forceps tip.

Results

For 20 lesions, the diagnostic yield was 85%. The primary EBUS images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. The primary CBCT images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. Primary EBUS and CBCT image types were equivalent in 14 cases. Of the 12 cases with type 1 primary EBUS image, 9 cases had a type 1 primary CBCT image, while 3 cases exhibited positional misalignment of the forceps tip. Re-navigation was required in 8 cases with types 2 and 3 primary CBCT images.

Conclusions

CBCT-guided TBB using an UTB and EBUS may enable real-time positioning guidance and better re-navigation in the diagnosis of peripheral pulmonary lesions.

Ex-vivo exploration of an endobronchial sentinel lymph node procedure in lung cancer for optimizing workflow and evaluating feasibility of novel imaging tools

Background

Early-stage lung cancer is treated with curative intent by surgery or radiotherapy. However, upstaging is frequently seen after surgery in clinical N0 lung cancer patients, and despite curative intent, 2-year recurrence rates of 9-28% are reported. A sentinel lymph node (SLN) procedure could improve the staging accuracy. We explored the feasibility of performing a navigation bronchoscopy based SLN procedure in human ex-vivo lung cancer specimens to optimize procedural parameters and assess a novel injection tool.

Methods

Ten lung resection specimens were included and allocated to either peri- or intratumoral injection of a tracer combining ^99mTc-nanocolloid and indocyanine green (ICG) while varying the injection volume. A Pioneer Plus catheter with a pre-angulated 24G needle and an ultrasound (US)-element was used to perform real-time US guided transbronchial injections at multiple locations. Thereafter, single photon emission computed tomography/computed tomography (SPECT/CT)-scanning was performed to image injection depots and to assess their location relative to the tumor.

Results

An average volume of 0.7 mL (range, 0.3-1.2 mL) with an average activity of 89.5 MBq ^99mTc (range, 35.4-188.0 MBq) was injected. Intratumoral injections in non-solid and solid tumors were successful in 100% and 64.3% respectively, while 100% of peritumoral injections in solid tumors were successful. The US-element of the catheter allowed real-time imaging and was able to visualize all tumors and 67.4% of all injections. SPECT/CT-scanning visualized 76.7% of the injection depots.

Conclusions

A navigation bronchoscopy mediated SLN procedure seems technically feasible. The Pioneer Plus is a suitable catheter to place tracer depots at multiple intra-/peri-tumoral sites, while receiving real-time feedback on the needle localization in relation to the tumor. The next step of in-vivo injections will determine if tracer drainage to the SLN can also be detected on pre- and per-operative imaging.

Mobile Cone-Beam CT-Assisted Bronchoscopy for Peripheral Lung Lesions

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.

Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy

Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL's benign or malignant nature, delaying the therapy's second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies.

Case report: multiple lesions during navigation bronchoscopy; seen one, seen them all?

Background

Peripheral pulmonary nodules are often detected as multiple nodules in one patient. Computed tomography (CT) guided transthoracic biopsy (TTNB) is the most widely implemented method for minimal invasive biopsy of pulmonary nodules, but generally only one nodule is sampled per procedure. Navigation bronchoscopy is an endobronchial procedure with very low complication rates, and uses high-end image guidance which allows for the sampling of multiple nodules in one session, while also allowing inspection of the central airways and endobronchial ultrasound (EBUS) guided staging in one session. This report presents a unique case with three different synchronous primary tumors treated with three different treatment modalities that highlights the added value of cone-beam CT guided navigation bronchoscopy (CBCT-NB) in the diagnostic work-up of suspected early-stage lung cancer.

Case Description

This case describes an asymptomatic patient with no history of prior lung cancer referred because of a shadow seen on a screening X-ray. CT and positron emission tomography (PET) showed two nodules for which a navigation procedure was performed. Both nodules were sampled, and on inspection, a third occult endobronchial lesion was also found. Pathology revealed three separate primary tumors, which were treated with three different treatment modalities: surgery, radiotherapy and endobronchial cryoablation. Current follow-up at 12 months shows no signs of recurrence.

Conclusions

This case highlights that synchronous primary malignancies do occur and require a patient tailored approach to minimize treatment related morbidity and optimize survival. To this goal, image guided navigation bronchoscopy allows for a full and complete diagnostic evaluation and can be combined with a staging EBUS in one single session.

Cone beam CT-guided navigation bronchoscopy: a cost-effective alternative to CT-guided transthoracic biopsy for diagnosis of peripheral pulmonary nodules

Objectives

To determine if cone beam CT-guided navigation bronchoscopy (CBCT-NB) is a cost-effective diagnostic procedure in patients with a pulmonary nodule (PN) with an intermediate risk for lung cancer.

Materials and methods

Two decision analytical models were developed to compare the long-term costs, survival and quality of life. In the first model, CBCT-NB was compared with CT-guided transthoracic needle biopsy (TTNB) in TTNB eligible patients. In the second model, CBCT-NB was compared with direct treatment (without pathology proven lung cancer) in patients for whom TTNB is not suitable. Input data were gathered in-house, from literature and expert opinion. Effects were expressed in quality-adjusted life years (QALYs). Sensitivity analyses were used to assess uncertainty.

Results

CBCT-NB can be cost-effective in TTNB eligible patients with an incremental cost-effectiveness ratio of €18 416 in an expert setting. The probabilistic sensitivity analysis showed that in 69% and 90% of iterations CBCT-NB remained cost-effective assuming a willingness to pay (WTP) of €20 000 and €80 000 per QALY. CBCT-NB dominated in the treatment strategy in which TTNB is not suitable. The probabilistic sensitivity analysis showed that in 95% of iterations CBCT-NB remained the dominant strategy, and CBCT-NB remained cost-effective in 100% of iterations assuming a WTP limit of €20 000. In the comparison between CBCT NB and TTNB, the deterministic sensitivity analysis showed that the diagnostic properties and costs of both procedures have a large impact on the outcome.

Conclusions

CBCT-NB seems a cost-effective procedure when compared with TTNB and when compared with a direct treatment strategy in patients with an intermediate risk PN.

Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study

Objective

To determine whether CT-to-body divergence can be overcome to improve the diagnostic yield of peripheral pulmonary nodules with the combination of shape-sensing robotic-assisted bronchoscopy (SSRAB) and portable 3-dimensional (3D) imaging.

Patients and Methods

A single-center, prospective, pilot study was conducted from February 9, 2021, to August 4, 2021, to evaluate the combined use of SSRAB and portable 3D imaging to visualize tool-in-lesion as a correlate to diagnostic yield.

Results

Thirty lesions were subjected to biopsy in 17 men (56.7%) and 13 women (43.3%). The median lesion size was 17.5 mm (range, 10-30 mm), with the median airway generation of 7 and the median distance from pleura of 14.9 mm. Most lesions were in the upper lobes (18, 60.0%). Tool-in-lesion was visualized at the time of the procedure in 29 lesions (96.7%). On the basis of histopathologic review, 22 (73.3%) nodules were malignant and 6 (20.0%) were benign. Two (6.7%) specimens were suggestive of inflammation, and the patients elected observation. The mean number of spins was 2.5 (±1.6) with a mean fluoroscopy time of 8.7 min and a mean dose area product of 50.3 Gy cm² (±32.0 Gy cm²). There were no episodes of bleeding or pneumothorax. The diagnostic yield was 93.3%.

Conclusion

This pilot study shows that the combination of mobile 3D imaging and SSRAB of pulmonary nodules appears to be safe and feasible. In conjunction with appropriate anesthetic pathways, nodule motion and divergence can be overcome in most patients.

Trial Registration

https://clinicaltrials.gov Identifier NCT04740047

Accuracy of Pulmonary Nodule Sampling Using Robotic Assisted Bronchoscopy with Shape Sensing, Fluoroscopy, and Radial Endobronchial Ultrasound (The ACCURACY Study)

BACKGROUND

Despite recent advances in guided bronchoscopy, the yield of bronchoscopic biopsy of a peripheral pulmonary nodule (PPN) remains highly variable.

OBJECTIVE

The aim of the study was to evaluate which features of robotic assisted bronchoscopy (RAB) contribute to a successful biopsy in a cadaver model.

METHODS

A preclinical, prospective, single-blinded trial using a ventilated human cadaveric model assessed the successful puncture of implanted pulmonary nodules using various localization techniques with RAB. The different approaches included positioning the robotic catheter at predefined distances from the target nodule (<10 mm, 10-20 mm, 20-30 mm), bronchoscopist correction of divergence between the software virtual map and bronchoscopic view if observed, and impact of fluoroscopy and radial endobronchial ultrasound (rEBUS). The primary endpoint was a central target hit (defined as an inner 2/3 target puncture) verified by cone-beam computed tomography.

RESULTS

Thirty-eight RAB procedures were performed to target 16 PPNs. Median nodule size was 16.2 mm. All targets were located in the outer 1/3 of the lung with a bronchus sign in 31.3%. Central target hit rates were improved when the robotic catheter tip was closer to the nodule (<10 mm 68%, 10-20 mm 66%, 20-30 mm 11%, p < 0.001). Multivariable analysis confirmed the strongest predictor of a central target hit was robotic catheter distance to nodule (OR 0.89 per increase in 1 mm, p < 0.001), independent of the presence of a bronchus sign, divergence or concentric rEBUS view.

CONCLUSIONS

Utilizing a RAB platform, closer proximity of the robotic catheter to the target nodule results in an increase in peripheral nodule biopsy success.

Effective early diagnosis for NSCLC: an algorithm

INTRODUCTION

Lung cancer still remains undiagnosed for most patients until the disease is inoperable.

AREAS COVERED

We performed search on PubMed with the keywords: EBUS, radial-EBUS, bronchoscopy, lung cancer, electromagnetic navigation, ct-biopsy, transthoracic biopsy. We present diagnostic equipment and imaging techniques such as positron emission tomography, endoscopical navigation systems, endobronchial ultrasound, radial-endobronchial ultrasound, transthoracic ultrasound biopsy, and computed tomography guided biopsies.

EXPERT OPINION

However, lack of early disease symptoms remains the most important issue and therefore we should direct our efforts to screening and early disease diagnosis. An algorithm is proposed for biopsy upon initial disease diagnosis.