Electromagnetic navigation bronchoscopic dye marking for localization of small subsolid nodules: Retrospective observational study

Use of a novel claw-suture technique for localization of solitary pulmonary nodules: retrospective study and experience from one center

Background

Video-assisted thoracoscopic surgery (VATS) is more effective for diagnosing and treating solitary pulmonary nodules (SPNs). It is sometimes difficult to localize through use of minimally invasive techniques. We evaluated the feasibility, effectiveness, and safety of a novel localization method for SPNs. Here, we describe our technical process, perioperative results, and accumulated experience over the years.

Methods

Between February 2018 and April 2023, a retrospective study of a novel claw-suture localization technique was conducted in a single center. A total of 490 patients participating in the localization of preoperative SPNs were enrolled. An anchor claw device with four hooks and three-colored sutures was used for localizing nodules under computed tomography (CT). We then evaluated the localization process and the outcomes of the operative procedure (success rate, safety, feasibility, and patient comfort).

Results

A total of 510 SPNs were localized before surgery, and the median size of the nodules was 0.70 cm (range, 0.4-2.0 cm). Additionally, 97.1% of these nodules (495 of 510) were localized successfully without dislodgment or device fracture. Types of failures included not meeting the target value of the distance between the claw and lesion (n=12, 2.4%) and displacement of the device (n=3, 0.6%). Pneumothorax (n=63, 12.4%), parenchymal hemorrhage (n=46, 9.0%), and hemothorax (n=1, 0.2%) were the most common complications that did not require further medical treatment. Pleural reactions were reported in 2 patients (0.4%). A notable correlation was also found between the depth of the pulmonary nodules and the incidence of parenchymal hemorrhage (P<0.001). The median length for the entire process was 12 minutes (7-25 minutes). No patients reported significant pain during the localization process, and the device was retrieved with a 100% survival rate after VATS resection.

Conclusions

This method of claw-suture localization is safe, effective, and feasible and can be used to localize SPNs that are challenging to locate before operation.

Electromagnetic navigation bronchoscopy-guided preoperative lung nodule localization in video-assisted thoracic surgery (VATS): a learning curve analysis

Background

Electromagnetic navigation bronchoscopy (ENB) has been widely used to mark small peripheral pulmonary nodules (PPNs) in video-assisted thoracic surgery (VATS) resection. This technique offers the advantages of a high accuracy and fewer complications. However, few studies have analyzed the learning curve of ENB-guided preoperative localization. We aimed to describe the learning curve and factors influencing ENB-guided thoracoscopic pulmonary nodule resection.

Methods

This study included 300 consecutive patients with PPNs who underwent ENB-guided localization by the same endoscopist in our department between November 2019 and December 2021. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB-guided localization and the learning curve in different lobes, while logistic regression was used to analyze the risk factors affecting ENB operative time (OT).

Results

In 184 patients with 300 nodules, three learning phases were identified through turning points of the learning curve: Phase I (the 16th nodule), Phase II (the 17th to the 107th nodule), and Phase III (the 107th to the 300th nodule). No significant difference was found in the success rate of ENB-guided localization in each phase of the learning curve (100%, 96.7%, and 97.9%, P=0.78). The distance from the localization to the pleura in Phase I was statistically significantly shorter than that in Phase II and Phase III (0.6±0.4 vs. 1.1±0.6 vs. 1.0±0.5 cm, P=0.001 and P=0.003). Furthermore, the learning curves for nodules in different lobes were different. The learning curve for the upper lobe nodules was divided into two phases; the learning curve for the middle lobe disclosed more negative values; and the learning curve for the lower lobe nodules displayed no obvious pattern. Significant differences were found in nodule location, distance from the localization to the pleura and learning curve phase (P=0.003, P<0.001, P=0.02). The independent factors for OT included gender, smoking history, nodule type, distance from localization to the pleura, and learning curve phase.

Conclusions

ENB OT at the 107th nodule leveled off and showed a downward trend. Different lobes have different learning curves, the middle lobe is the easiest lobe to learn with ENB and can be used as the first lobe of choice for beginners. The learning curve can objectively evaluate the accuracy of ENB location and help endoscopists identify areas for improvement.

Preoperative localization of pulmonary nodules by electromagnetic navigation bronchoscopy combined with methylene blue injection

Background

Electromagnetic navigation bronchoscopy (ENB) can help to accurately locate pulmonary nodules using a minimally invasive approach. This study sought to evaluate the clinical efficacy and safety of dye marking localization under the guidance of ENB followed by surgery.

Methods

A retrospective analysis was performed of 61 patients who underwent ENB localization using methylene blue dye marking before surgery at Shanghai General Hospital from October 2021 to February 2022. The clinical efficacy and safety of ENB localization and the related factors affecting the navigation time of ENB location were analyzed.

Results

ENB was performed on 170 pulmonary nodules in 61 patients with a median age of 60 [interquartile range (IQR), 18] years. The majority of patients (70.69%) had more than two pulmonary nodules. The median maximum nodule diameter was 10 (IQR, 8) mm, and 48.21% of the nodules were mixed ground-glass nodules. Median time for ENB navigation was 10.5 (IQR, 6) min. The navigation success rate was 92.96%, and the ENB location success rate was 95.89%. The rate of complications related to ENB localization was 1.64% (there was only one case of pulmonary hemorrhage). The multivariate analysis showed that the factors related to the navigation time included the node location (P=0.001) and location mode (P=0.04).

Conclusions

ENB-guided methylene blue injection is an effective and safe tool for localizing and marking pulmonary nodules, and can be used to assist the diagnosis and treatment of early lung cancer. The node location and location mode had significant effects on navigation time.

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.

Preoperative localization for lung nodules: a meta-analysis of bronchoscopic versus computed tomography guidance

Introduction

Both computed tomography (CT)-guided and bronchoscopic localization strategies have been utilized prior to video-assisted thoracic surgery (VATS) as a means of achieving high lung nodule (LN) wedge resection success rates.

Aim

The present meta-analysis was thus developed for the assessment of the efficacy and safety of preoperative CT-guided and bronchoscopic LN localization approaches.

Material and methods

The PubMed, Cochrane Library, Embase, and Wanfang databases were searched for all relevant studies published through May 2022, with RevMan v5.3 being used to conduct pooled analyses of data pertaining to all endpoints of interest.

Results

In total, this meta-analysis incorporated data from 7 retrospective studies including 321 patients bearing 353 LNs that underwent CT-guided localization and 220 patients bearing 244 LNs that underwent bronchoscopic localization. When comparing the CT and bronchoscopic localization approaches, pooled rates of technical success (p = 0.20) and duration of localization (p = 0.20) were comparable. However, bronchoscopic localization was associated with significantly lower pooled rates of pneumothorax (p < 0.001) and pulmonary hemorrhage (p = 0.005) relative to CT-guided localization. In the CT group, the pooled VATS duration was significantly shorter compared with the bronchoscopic group (p = 0.04), although the pooled duration of postoperative hospitalization was comparable in both groups (p = 0.69). The heterogeneity was significant with respect to both the duration of localization (I² = 97%) and the duration of postoperative hospitalization (I² = 74%).

Conclusions

Relative to a CT-guided localization approach, the bronchoscopic localization of LNs can achieve similar clinical efficacy and superior safety.

[Application and Progress of Electromagnetic Navigation Bronchoscopy in Department of Thoracic Surgery]

Lung cancer ranks the first cancer-related morbidity and mortality in China. With the development and penetration of imaging technology, increasing small pulmonary peripheral Nodules (SPPNs) have been detected. However, precise location and diagnosis of SPPNs is still a tough problem for clinical diagnosis and treatment in department of thoracic surgery. With the development of electromagnetic navigation bronchoscopy (ENB), it provides a novel minimally invasive method for the diagnosis and treatment of SPPNs. In this review, we summarized the application and progress of ENB in preoperative positioning, diagnosis, and local treatment, then, discussed the clinical application of ENB in the hybrid operating room.
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Management of Ground-Glass Nodules: When and How to Operate?

Simple Summary

An increasing number of lung cancer screening programs have detected the frequent occurrence of small pulmonary ground-glass nodules (GGNs). If GGN is an incidental finding, it should be followed according to the guidelines. A multidisciplinary team discussion should be initiated if a new solid component develops or the solid portion grows on follow-up CT. Preoperative attempts to biopsy solid components in part-solid GGNs are often not feasible and not helpful. If malignancy is suspected, a surgical biopsy with the guidance of various localization methods is recommended. Once the GGN is confirmed to be malignant, sub-lobar resection may be reasonable in the majority of cases, and the extent of lung resection should be determined based on the CT finding or intraoperative frozen section examination using special inflation technique. Although rare, the recurrence in the remaining lobe can occur especially in patients with high risk histologic features, which currently cannot accurately diagnosed either pre- or intra-operatively.

Abstract

With the increased popularity of low-dose computed tomography (LDCT), many patients present with pulmonary ground-glass nodules (GGNs), and the appropriate diagnostic and management strategy of those lesions make physicians be on the horn of the clinical dilemma. As there is not enough data available to set universally acceptable guidelines, the management of GGNs may be different. If GGN is an incidental finding through LDCT, the lesion should be followed according to the current guidelines. We recommend a multidisciplinary team discussion to be initiated if a new solid component develops or the solid portion size grows on follow-up CT as the risk of malignancy is high. Attempts to preoperatively biopsy solid components in part-solid GGNs are often not feasible and not helpful in clinical settings. Currently, if malignancy is suspected, a surgical biopsy with the guidance of various localization methods is recommended. If malignancy is confirmed, sub-lobar resection may provide an excellent oncologic outcome.

Electromagnetic navigational bronchoscopy-guided dye marking to identify the subsegmental bronchus in thoracoscopic anatomic subsegmentectomy

Video‐assisted thoracoscopic surgery (VATS) subsegmentectomy has been widely used to resect small‐sized lung lesions in clinical practice. Precise identification of the subsegmental bronchus is one of the essential steps in performing thoracoscopic anatomic subsegmentectomy. Here, we report a thoracoscopic right S²a segmentectomy with preoperative electromagnetic navigational bronchoscopy (ENB)‐guided injection of methylene blue to identify the subsegmental bronchus in a 51‐year‐old male. We successfully performed complicated surgery using this method. This ENB‐guided dye marking method may accurately distinguish the subsegmental bronchus to effectively guide surgery.

Electromagnetic Navigation Bronchoscopy-Guided Dye Marking for Localization of Pulmonary Nodules

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB)-guided dye marking is a useful localization modality for small pulmonary nodules. The purpose of this study was to evaluate the efficacy and safety of intraoperative full virtual ENB-guided dye marking.

METHODS

Patients who underwent full virtual ENB-guided dye marking without adjunct intraoperative imaging (fluoroscopy or cone beam computed tomography) for small pulmonary nodules were investigated retrospectively. Efficacy was evaluated on the basis of the success rates of dye marking (visible dye mark) and nodule localization, and safety was evaluated on the basis of the rate of ENB-related complications.

RESULTS

ENB-guided dye marking was performed on 164 nodules in 134 patients. Twenty-seven (20.1%) patients had multiple nodules. The total number of dye-marking attempts was 241, and the mean number of markings per nodule was 1.5±0.7. The mean ENB procedure duration was 30±15.1 min. No ENB-related complications were observed. The success rate of dye marking was 86.7% (209/241), and that of localization was 94.5% (155/164). Among 63 nodules with multiple dye-marking attempts, 62 (98.4%) were successfully localized. In 101 nodules with a single dye-marking attempt, 88 (87.1%) were localized with the visceral pleural dye mark. Additionally, 6 (5.9%) nodules could be localized with the needle hole on the visceral pleura. The number of dye-marking attempts was a significant factor in the success of localization (1.5±0.7 versus 1.1±0.3, p=0.01).

CONCLUSIONS

Full virtual ENB-guided dye marking was effective and safe for the localization of small pulmonary nodules. A multiple dye-marking strategy is recommended to achieve a high success rate.

Clock dial integrated positioning combined with single utility port video-assisted thoracoscopic surgery: a new localization method for lung tumors

Background

Preoperative localization of lung tumor mainly consisted of two methods: CT-guided percutaneous localization and electromagnetic navigation bronchoscopy-guided localization. However, these invasive methods could result in serious complications. In order to avoid the adverse effects of preoperative invasive localization, we propose a method of intraoperative noninvasive localization for lung tumors: clock dial integrated positioning (CDIP).

Methods

To retrospectively analyze the clinic data about the application of CDIP for 127 lung tumour patients in single utility port video-assisted thoracoscopic surgery (SUPVATS) between June 2017 and October 2017.

Results

One hundred and twenty-four cases (97.64%) underwent thoracoscopic surgery, which including 14 lobectomy, 107 partial resection, 2 lobectomy plus partial resection and 1 left pneumonectomy. Three cases (2.36%) underwent thoracoscopic biopsy. The mean operation time and intraoperative bleeding were 47.9±22.1 min and 70.1±40.3 mL, respectively. The mean postoperative hospital stay and chest drain duration were 3.9±2.2 and 3.6±1.8 days, respectively. There were 118 cases of malignant tumors, including adenocarcinoma (n=101), squamous cell carcinoma (n=9), large cell carcinoma (n=2), small cell lung carcinoma (n=3), and metastatic lung carcinoma (n=3). The remaining nine cases were benign tumors, including granuloma (n=3), intrapulmonary lymph node (n=2), sclerosing hemangioma (n=2), and hamartoma (n=2). The incidence of postoperative complications was 10.2%. There was no mortality, secondary operation, or conversion to open procedure due to massive intraoperative bleeding.

Conclusions

CDIP combined with SUPVATS is a safe, feasible, and effective method for the localization of lung tumors. This novel method can provide a reliable alternative technique when the marker is dislocated.

Electromagnetic navigation bronchoscopic localization versus percutaneous CT-guided localization for thoracoscopic resection of small pulmonary nodules

BACKGROUND

Identification of small pulmonary nodules is challenging in a limited intrathoracic field during minimally invasive video-assisted thoracoscopic surgery (VATS), and preoperative localization is required. Various techniques have been reported with some failure and complications. Here, we compare the feasibility and safety between electromagnetic navigation bronchoscopic marking and computed tomography (CT)-guided percutaneous marking using indocyanine green (ICG) and iopamidol.

METHODS

A total of 47 patients with small-sized pulmonary nodules, scheduled to undergo video-assisted thoracoscopic limited resection, were enrolled in this study. A mixture of diluted ICG and iopamidol was injected into the lung parenchyma as a marker, using CT-guided percutaneous or electromagnetic navigation bronchoscopic injection techniques and the results were examined and compared.

RESULTS

A total of 35 and 12 patients underwent preoperative marking by percutaneous injection and electromagnetic navigation bronchoscopic injection, respectively, in which a marker was detected in 33/35 (94.3%) and 12/12 (100%) patients. No combination of these procedures was performed in any patient. All markers were successfully detected in three patients who underwent injection marking at two different lesion sites. Pneumothorax occurred in five patients (14%) in the percutaneous marking group, which was relieved in all patients without the necessity for chest tube drainage. No other complication was observed in this study.

CONCLUSIONS

Electromagnetic navigation bronchoscopic injection techniques using indocyanine green fluorescence plus iopamidol are safe and effective, and comparable with CT-guided localization. Furthermore, a bronchoscopic approach enables marking of multiple lesion areas without increasing patient risk, especially for puncture-related pneumothorax.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Either computed tomography (CT)-guided percutaneous or electromagnetic navigation bronchoscopic injection techniques can be used for preoperative marking of pulmonary nodules with indocyanine green (ICG) fluorescence.

WHAT THIS STUDY ADDS

Indocyanine green (ICG) is a safe and easily detectable fluorescent marker for video-assisted thoracoscopic surgery (VATS). A bronchoscopic injection approach enables marking of multiple lesion areas without increasing the risk of pneumothorax.

Feasibility of electromagnetic navigation bronchoscopy-guided lung resection for pulmonary ground-glass opacity nodules

Background

Recent advances in imaging modalities and recommended low-dose computed tomography screening programs have made it easier to diagnose early lung cancer. However, the diagnosis of small ground-glass nodules (GGNs) has been problematic due to inappropriate specimen procurement and failure of conventional percutaneous core needle biopsy. Thus, we aimed to evaluate the usefulness of electromagnetic navigation bronchoscopy (ENB)-guided video-assisted lung resection for not only the diagnosis but also treatment of GGNs.

Methods

From 2017 to 2019, 110 patients with suspicious lung cancer lesions that were not diagnosed by conventional procedure underwent ENB-guided lung resection. Among 35 cases of GGNs, 33 cases of localization were included in this study (two cup biopsy cases were excluded). We used SuperDimension™ for the ENB procedure. After general anesthesia, indigo carmine (0.3–0.5 mL) was injected, and GGNs were resected through video-assisted thoracoscopic surgery.

Results

Of the 33 GGNs, 16 were pure (2 adenocarcinomas in situ, 5 minimally invasive adenocarcinomas (MIAs), 3 adenocarcinomas, and 6 benign lesions) and 17 were mixed (1 MIA, 11 adenocarcinomas, and 5 benign lesions). The mean size of all lesions was 11.2±7.78 mm, mean distance to the pleura was 11.2±14.2 mm, and mean ENB procedure time was 18.8±8.88 minutes. Dye localization and surgical resection of GGN were successful in all cases. There was no procedure-related complication.

Conclusions

ENB is a feasible and highly accurate localization method for minimally invasive lung resection of small GGNs.

Navigational bronchoscopy: a guide through history, current use, and developing technology

The peripheral pulmonary nodule offers unique challenges to the clinician, especially in regards to diagnostic approach. Quite often the etiology of the nodule is spurious, though the specter of malignancy drives accurate classification of the nodule. Diagnostic approaches range in degrees of invasiveness, accuracy, and morbidity. Bronchoscopic access to these nodules had been plagued by low reported yields, especially in fluoroscopically invisible nodules. Navigational bronchoscopy, however, allowed more accurate access to peripheral nodules while maintaining a low morbidity, and thus reshaped the historic diagnostic algorithms. Though navigational bronchoscopy was initially associated with electromagnetic navigation, newer approaches to navigation and new technologies provide enthusiasm that yield can improve. In this article we will provide a historical approach to navigational bronchoscopy, from its origins to its current state, and we will discuss developing technology and its potential role in the evolving paradigm of the peripheral nodule biopsy.

Navigation Bronchoscopy

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