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Kim SH, Chung HS, Kim J, Kim MH, Lee MK, Kim I, Eom JS. Development of the Korean Association for Lung Cancer Clinical Practice Guidelines: Recommendations on Radial Probe Endobronchial Ultrasound for Diagnosing Lung Cancer - An Updated Meta-Analysis. Cancer Res Treat 2024; 56:464-483. [PMID: 38037321 PMCID: PMC11016639 DOI: 10.4143/crt.2023.749] [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: 06/12/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
PURPOSE Radial probe endobronchial ultrasound (RP-EBUS) accurately locates peripheral lung lesions (PLLs) during transbronchial biopsy (TBB). We performed an updated meta-analysis of the diagnostic yield of TBB for PLLs using RP-EBUS to generate recommendations for the development of the Korean Association of Lung Cancer guidelines. MATERIALS AND METHODS We systematically searched MEDLINE and EMBASE (from January 2013 to December 2022), and performed a meta-analysis using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total lesion number. Subgroup analysis was performed to identify related factors. RESULTS Forty-one studies with a total of 13,133 PLLs were included. The pooled diagnostic yield of RP-EBUS was 0.72 (95% confidence interval [CI], 0.70 to 0.75). Significant heterogeneity was observed among studies (χ2=292.38, p < 0.01, I2=86.4%). In a subgroup analysis, there was a significant difference in diagnostic yield based on RP-EBUS findings (within, adjacent to, invisible), with a risk ratio of 1.45 (95% CI, 1.23 to 1.72) between within and adjacent to, 4.20 (95% CI, 1.89 to 9.32) between within and invisible, and 2.59 (95% CI, 1.32 to 5.01) between adjacent to and invisible. There was a significant difference in diagnostic yield based on lesion size, histologic diagnosis, computed tomography (CT) bronchus sign, lesion character, and location from the hilum. The overall complication rate of TBB with RP-EBUS was 6.8% (bleeding, 4.5%; pneumothorax, 1.4%). CONCLUSION Our study showed that TBB with RP-EBUS is an accurate diagnostic tool for PLLs with good safety profiles, especially for PLLs with within orientation on RP-EBUS or positive CT bronchus sign.
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Affiliation(s)
- Soo Han Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyun Sung Chung
- Division of Pulmonology, National Cancer Center, Goyang, Korea
| | - Jinmi Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Biostatistics, Pusan National University Hospital, Busan, Korea
| | - Mi-Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Insu Kim
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Zhang J, Chen E, Xu S, Xu L, Hu H, Dong L, Ying K. Virtual bronchoscopic navigation with intraoperative cone-beam CT for the diagnosis of peripheral pulmonary nodules. BMC Pulm Med 2024; 24:146. [PMID: 38509516 PMCID: PMC10956201 DOI: 10.1186/s12890-024-02930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Transbronchial biopsy is a safe manner with fewer complications than percutaneous transthoracic needle biopsy; however, the current diagnostic yield is still necessitating further improvement. We aimed to evaluate the diagnostic yield of using virtual bronchoscopic navigation (VBN) and cone-beam CT (CBCT) for transbronchial biopsy and to investigate the factors that affected the diagnostic sensitivity. METHODS We retrospectively investigated 255 patients who underwent VBN-CBCT-guided transbronchial biopsy at our two centers from May 2021 to April 2022. A total of 228 patients with final diagnoses were studied. Patient characteristics including lesion size, lesion location, presence of bronchus sign, lesion type and imaging tool used were collected and analyzed. Diagnostic yield was reported overall and in groups using different imaging tools. RESULTS The median size of lesion was 21 mm (range of 15.5-29 mm) with 46.1% less than 2 cm in diameter. Bronchus sign was present in 87.7% of the patients. The overall diagnostic yield was 82.1%, and sensitivity for malignancy was 66.3%. Patients with lesion > 2 cm or with bronchus sign were shown to have a significantly higher diagnostic yield. Four patients had bleeding and no pneumothorax occurred. CONCLUSION Guided bronchoscopy with VBN and CBCT was an effective diagnostic method and was associated with a high diagnostic yield in a safe manner. In addition, the multivariant analysis suggested that lesion size and presence of bronchus sign could be a predictive factor for successful bronchoscopic diagnosis.
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Affiliation(s)
- Jisong Zhang
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Enguo Chen
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Shan Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Li Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Huihui Hu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Liangliang Dong
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Kejing Ying
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China.
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Lachkar S, Guisier F, Thiberville L, Dantoing E, Salaün M. [Advanced bronchoscopic techniques for the diagnosis of peripheral lung nodule]. Rev Mal Respir 2023; 40:810-819. [PMID: 37798173 DOI: 10.1016/j.rmr.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/25/2023] [Indexed: 10/07/2023]
Abstract
The endoscopic diagnosis of peripheral lung nodules is a challenging aspect of oncological practice. More often than not inaccessible by traditional endoscopy, these nodules necessitate multiple imagery tests, as well as diagnostic surgery for benign lesions. Even though transthoracic ultrasonography has a high diagnostic yield, a sizeable complication rate renders it suboptimal. Over recent years, a number of safe and accurate navigational bronchoscopic procedures have been developed. In this first part, we provide an overview of the bronchoscopic techniques currently applied for the excision and diagnostic analysis of peripheral lung nodules; emphasis is laid on electromagnetic navigation bronchoscopy and the association of virtual bronchoscopy planner with radial endobronchial ultrasound. We conclude by considering recent innovations, notably robotic bronchoscopy.
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Affiliation(s)
- S Lachkar
- Department of Pneumology, CHU de Rouen, 76000 Rouen, France.
| | - F Guisier
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
| | - L Thiberville
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
| | - E Dantoing
- Department of Pneumology, CHU de Rouen, 76000 Rouen, France
| | - M Salaün
- Department of Pneumology, UNIROUEN, LITIS Lab QuantIF team EA4108, CHU de Rouen, Normandie University, Inserm CIC-CRB 1404, 76000 Rouen, France
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4
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Oki M. Ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions. Respir Investig 2023; 61:711-719. [PMID: 37708637 DOI: 10.1016/j.resinv.2023.07.008] [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: 07/01/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 09/16/2023]
Abstract
Bronchoscopes are continuously improving. Increasingly, thinner bronchoscopes with larger working channels and better imaging quality are becoming available for clinical use. Concurrently, useful ancillary devices have been developed, such as radial probe endobronchial ultrasound (rEBUS) and navigation devices. Randomized studies have demonstrated the diagnostic superiority of ultrathin bronchoscopy over thin bronchoscopy under rEBUS and virtual bronchoscopic navigation guidance for small, peripheral pulmonary lesions. Furthermore, biopsy needles and cryoprobes have been miniaturized and adapted to the working channel of the new ultrathin bronchoscopes. Multi-modality and multi-instrumental ultrathin bronchoscopy using such new technologies has facilitated high diagnostic yields.
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Affiliation(s)
- Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, 460-000, Japan.
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5
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Hu Z, Tian S, Wang X, Wang Q, Gao L, Shi Y, Li X, Tang Y, Zhang W, Dong Y, Bai C, Huang H. Predictive value of the resistance of the probe to pass through the lesion in the diagnosis of peripheral pulmonary lesions using radial probe endobronchial ultrasound with a guide sheath. Front Oncol 2023; 13:1168870. [PMID: 37588089 PMCID: PMC10425773 DOI: 10.3389/fonc.2023.1168870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/17/2023] [Indexed: 08/18/2023] Open
Abstract
Background Transbronchial lung biopsy guided by radial probe endobronchial ultrasonography with a guide sheath (EBUS-GS-TBLB) is becoming a significant approach for diagnosing peripheral pulmonary lesions (PPLs). We aimed to explore the clinical value of the resistance of the probe to pass through the lesion in the diagnosis of PPLs when performing EBUS-GS-TBLB, and to determine the optimum number of EBUS-GS-TBLB. Methods We performed a prospective, single-center study of 126 consecutive patients who underwent EBUS-GS-TBLB for solid and positive-bronchus-sign PPLs where the probe was located within the lesion from September 2019 to May 2022. The classification of probe resistance for each lesion was carried out by two bronchoscopists independently, and the final result depended on the bronchoscopist responsible for the procedures. The primary endpoint was the diagnostic yield according with the resistance pattern. The secondary endpoints were the optimum number of EBUS-GS-TBLB and factors affecting diagnostic yield. Procedural complications were also recorded. Results The total diagnostic yield of EBUS-GS-TBLB was 77.8%, including 83.8% malignant and 67.4% benign diseases (P=0.033). Probe resistance type II displayed the highest diagnostic yield (87.5%), followed by type III (81.0%) and type I (61.1%). A significant difference between the diagnostic yield of malignant and benign diseases was detected in type II (P = 0.008), whereas others did not. Although most of the malignant PPLs with a definitive diagnosis using EBUS-GS-TBLB in type II or type III could be diagnosed in the first biopsy, the fourth biopsy contributed the most sufficient biopsy samples. In contrast, considerably limited tissue specimens could be obtained for each biopsy in type I. The inter-observer agreement of the two blinded bronchoscopists for the classification of probe resistance was excellent (κ = 0.84). Conclusion The probe resistance is a useful predictive factor for successful EBUS-GS-TBLB diagnosis of solid and positive-bronchus-sign PPLs where the probe was located within the lesion. Four serial biopsies are appropriate for both probe resistance type II and type III, and additional diagnostic procedures are needed for type I.
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Affiliation(s)
- Zhenli Hu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Sen Tian
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Respiratory and Critical Care Medicine, No. 906 Hospital of the Chinese People's Liberation Army Joint Logistic Support Force, Ningbo, China
| | - Xiangqi Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Qin Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Li Gao
- Department of Pathology, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yuxuan Shi
- Department of Nephrology, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Respiratory and Critical Care Medicine, General Hospital of Central Theater Command of Chinese People’s Liberation Army, Wuhan, China
| | - Yilian Tang
- Basic Medical School, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yuchao Dong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Chong Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Haidong Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
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Kops SEP, Heus P, Korevaar DA, Damen JAA, Idema DL, Verhoeven RLJ, Annema JT, Hooft L, van der Heijden EHFM. Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis. Lung Cancer 2023; 180:107196. [PMID: 37130440 DOI: 10.1016/j.lungcan.2023.107196] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Navigation bronchoscopy has seen rapid development in the past decade in terms of new navigation techniques and multi-modality approaches utilizing different techniques and tools. This systematic review analyses the diagnostic yield and safety of navigation bronchoscopy for the diagnosis of peripheral pulmonary nodules suspected of lung cancer. METHODS An extensive search was performed in Embase, Medline and Cochrane CENTRAL in May 2022. Eligible studies used cone-beam CT-guided navigation (CBCT), electromagnetic navigation (EMN), robotic navigation (RB) or virtual bronchoscopy (VB) as the primary navigation technique. Primary outcomes were diagnostic yield and adverse events. Quality of studies was assessed using QUADAS-2. Random effects meta-analysis was performed, with subgroup analyses for different navigation techniques, newer versus older techniques, nodule size, publication year, and strictness of diagnostic yield definition. Explorative analyses of subgroups reported by studies was performed for nodule size and bronchus sign. RESULTS A total of 95 studies (n = 10,381 patients; n = 10,682 nodules) were included. The majority (n = 63; 66.3%) had high risk of bias or applicability concerns in at least one QUADAS-2 domain. Summary diagnostic yield was 70.9% (95%-CI 68.4%-73.2%). Overall pneumothorax rate was 2.5%. Newer navigation techniques using advanced imaging and/or robotics(CBCT, RB, tomosynthesis guided EMN; n = 24 studies) had a statistically significant higher diagnostic yield compared to longer established techniques (EMN, VB; n = 82 studies): 77.5% (95%-CI 74.7%-80.1%) vs 68.8% (95%-CI 65.9%-71.6%) (p < 0.001).Explorative subgroup analyses showed that larger nodule size and bronchus sign presence were associated with a statistically significant higher diagnostic yield. Other subgroup analyses showed no significant differences. CONCLUSION Navigation bronchoscopy is a safe procedure, with the potential for high diagnostic yield, in particular using newer techniques such as RB, CBCT and tomosynthesis-guided EMN. Studies showed a large amount of heterogeneity, making comparisons difficult. Standardized definitions for outcomes with relevant clinical context will improve future comparability.
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Affiliation(s)
- Stephan E P Kops
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Pauline Heus
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Johanna A A Damen
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Demy L Idema
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roel L J Verhoeven
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Oki M, Saka H, Kogure Y, Niwa H, Yamada A, Torii A, Kitagawa C. Ultrathin bronchoscopic cryobiopsy of peripheral pulmonary lesions. Respirology 2023; 28:143-151. [PMID: 36066209 DOI: 10.1111/resp.14360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Ultrathin bronchoscopy aids in the diagnosis of peripheral pulmonary lesions. However, both the working channel and the specimens are small. A 1.1-mm ultrathin cryoprobe that can enter the working channel of the ultrathin bronchoscope is now available, which may overcome the limitations of small specimen size. The aim of this study was to evaluate the feasibility, efficacy and safety of ultrathin bronchoscopic cryobiopsy using an ultrathin cryoprobe for diagnosing peripheral pulmonary lesions. METHODS Patients with peripheral pulmonary lesions ≤30 mm in diameter were prospectively enrolled in the study. All patients underwent forceps biopsy followed by cryobiopsy using a 3.0-mm ultrathin bronchoscope under radial probe endobronchial ultrasound guidance, virtual bronchoscopic navigation and fluoroscopic guidance. The primary endpoint was the feasibility of cryobiopsy. RESULTS In total, 50 patients with peripheral pulmonary lesions were enrolled in the study; the median longest diameter on computed tomography was 17.9 mm. Cryobiopsy was performed successfully in 49 patients (98%). Forceps biopsy, cryobiopsy and the combination of these two methods provided a specific diagnosis in 54% (27/50), 62% (31/50) and 74% (37/50) of patients, respectively. The median size of specimens obtained via cryobiopsy was significantly larger than the median size obtained via forceps biopsy (7.0 vs. 1.3 mm2 , respectively, p < 0.001). Mild bleeding during cryobiopsy occurred in 47 patients (94%). No moderate/severe bleeding or pneumothorax occurred. CONCLUSION Ultrathin bronchoscopic cryobiopsy is feasible, effective and sufficiently safe for the diagnosis of peripheral pulmonary lesions.
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Affiliation(s)
- Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.,Department of Respiratory Medicine, Matsunami General Hospital, Gifu, Japan
| | - Yoshihito Kogure
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hideyuki Niwa
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Arisa Yamada
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Atsushi Torii
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Chiyoe Kitagawa
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Oki M, Saka H, Himeji D, Imabayashi T, Nishii Y, Ando M. Value of adding ultrathin bronchoscopy to thin bronchoscopy for peripheral pulmonary lesions: A multicentre prospective study. Respirology 2023; 28:152-158. [PMID: 36288803 DOI: 10.1111/resp.14397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE The diagnostic yield of thin bronchoscopy with radial probe endobronchial ultrasound (rEBUS) of peripheral pulmonary lesions into which the rEBUS probe cannot be inserted is unsatisfactory. In such cases, adding ultrathin bronchoscopy may be an option. We evaluated the efficacy of sequential ultrathin bronchoscopy for peripheral pulmonary lesions into which the rEBUS probe could not be inserted during thin bronchoscopy. METHODS In this multicentre prospective study, patients with peripheral pulmonary lesions ≤30 mm in diameter underwent rEBUS-guided transbronchial biopsy using a 4.0 mm diameter thin bronchoscope. In patients with lesions into which a rEBUS probe could not be inserted using that bronchoscope, bronchoscopy using a 3.0 mm diameter ultrathin bronchoscope was performed. RESULTS A total of 342 patients were enrolled and 340 were analysed. Among them, 87 patients with lesions of a median longest diameter of 17.5 mm underwent thin bronchoscopy followed by ultrathin bronchoscopy. Of the 87 patients, the rEBUS probe was successfully inserted into the lesions via the ultrathin bronchoscope in 50 patients (57.5%). Of the 87 patients, the diagnostic yields of thin bronchoscopy and ultrathin bronchoscopy were 12.6% (11 of 87) and 41.4% (36 of 87), respectively (p < 0.001). CONCLUSION Ultrathin bronchoscopy affords a higher diagnostic yield for lesions into which a rEBUS probe cannot be inserted via a thin bronchoscope.
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Affiliation(s)
- Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Tatsuya Imabayashi
- Department of Pulmonary Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoichi Nishii
- Respiratory Center, Matsusaka Municipal Hospital, Matsusaka, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
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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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Chen H, Yu X, Yu Y, Zheng L, Zhuang Q, Chen Z, Deng Z. Diagnostic performance of cryobiopsy guided by radial-probe EBUS with a guide sheath for peripheral pulmonary lesions. J Bras Pneumol 2023; 49:e20220200. [PMID: 36629733 PMCID: PMC9970367 DOI: 10.36416/1806-3756/e20220200] [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: 06/07/2022] [Accepted: 10/31/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Transbronchial lung cryobiopsy (TBCB) has developed rapidly and has become one of the research hotspots of lung biopsy technology. The present study sought to evaluate the efficacy of TBCB guided by radial-probe EBUS (RP-EBUS) and a guide sheath (GS) without fluoroscopy for peripheral pulmonary lesions. METHODS In this retrospective study, McNemar's test was used in order to compare TBCB and transbronchial forceps biopsy (TBFB) in terms of diagnostic performance. A multivariate logistic regression model was designed to explore the association between predictive variables and the diagnostic yield of TBCB. RESULTS A total of 168 patients underwent GS-guided RP-EBUS. Of those, 157 had lesions that were visible and 11 had lesions that were not. Of those 157 patients, 24 were excluded because of missing data or an unclear final diagnosis. Therefore, 133 patients underwent RP-EBUS-GS-guided TBFB and TBCB. The pooled diagnostic yield of RP-EBUS-GS-guided TBCB without fluoroscopy was 71.5% (103/144). In 133 patients, the diagnostic yield of TBCB was significantly higher than that of TBFB (77.4% vs. 59.4%; p < 0.05). Multivariate analysis indicated that lesion size and site were independently associated with the diagnostic yield of TBCB (OR = 2.8, p = 0.03 and OR = 4.1, p = 0.01, respectively), although cryoprobe size was not. There was no significant difference between the 1.1-mm cryoprobe and the 1.9-mm cryoprobe in terms of diagnostic performance (78.4% vs. 76.8%; p > 0.05). CONCLUSIONS GS-guided RP-EBUS is regarded as a practical option for guiding cryobiopsy, although it may not be able to replace fluoroscopy. Peripheral pulmonary lesions not located in the upper lobes or larger than 30 mm are significantly associated with a higher diagnostic yield of cryobiopsy.
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Affiliation(s)
- Hui Chen
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Xuechan Yu
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Yiming Yu
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Lin Zheng
- . Department of Microbiology, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Qidong Zhuang
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Zhongbo Chen
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
| | - Zaichun Deng
- . Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Jiangbei District, Ningbo, Zhejiang Province, China
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11
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Kim SH, Kim J, Pak K, Eom JS. Ultrathin Bronchoscopy for the Diagnosis of Peripheral Pulmonary Lesions: A Meta-Analysis. Respiration 2023; 102:34-45. [PMID: 36412624 PMCID: PMC9843548 DOI: 10.1159/000527362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ultrathin bronchoscopy (external diameter, ≤3.5 mm) is useful for the diagnosis of peripheral pulmonary lesions because of its good accessibility. OBJECTIVES We performed a meta-analysis to investigate the diagnostic yield of ultrathin bronchoscopy for peripheral pulmonary lesions. METHODS We performed a systematic search of MEDLINE and EMBASE (from inception to May 2021), and meta-analysis was performed using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total number of lesions, and subgroup analysis was performed to identify related factors. RESULTS Nineteen studies with a total of 1,977 peripheral pulmonary lesions were included. The pooled diagnostic yield of ultrathin bronchoscopy was 0.65 (95% confidence interval, 0.60-0.70). Significant heterogeneity was observed among studies (χ2, 87.75; p < 0.01; I2, 79.5%). In a subgroup analysis, ultrathin bronchoscopy with 1.2 mm channel size showed a diagnostic yield of 0.61 (95% confidence interval, 0.53-0.68), whereas ultrathin bronchoscopy with 1.7 mm channel size showed 0.70 (95% confidence interval, 0.66-0.74) (χ2, 5.35; p = 0.02). In addition, there was a significant difference in diagnostic yield based on lesion size, histologic diagnosis (malignant vs. benign), bronchus sign, and lesion location from the hilum, whereas no significant difference was found based on lobar location. The overall complication rate of ultrathin bronchoscopy was 2.7% (pneumothorax, 1.1%). CONCLUSIONS Ultrathin bronchoscopy is an excellent tool for peripheral pulmonary lesion diagnosis with a low complication rate. The diagnostic yield of ultrathin bronchoscopy was significantly higher with larger channel size, which might be attributed to the availability of radial endobronchial ultrasound.
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Affiliation(s)
- Soo Han Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jinmi Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea,Department of Biostatistics, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, Republic of Korea
| | - Kyoungjune Pak
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea,Department of Nuclear Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, Republic of Korea,*Kyoungjune Pak,
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea,**Jung Seop Eom,
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12
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Chen H, Yu Y, Yu X, Li S, Zheng L, Zhang S, Zhuang Q, Deng Z, Chen Z. An Innovative Method: Predicting the Visibility of Radial Endobronchial Ultrasound for Peripheral Pulmonary Nodules by Virtual Bronchoscopic Navigation. Technol Cancer Res Treat 2022; 21:15330338221141790. [PMID: 36529905 PMCID: PMC9772973 DOI: 10.1177/15330338221141790] [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] [Indexed: 12/23/2022] Open
Abstract
Background: The diagnosis of peripheral pulmonary nodules (PPNs) still is the key and difficult point. Previous studies have demonstrated that the diagnostic yield of radial endobronchial ultrasound (rEBUS) visible nodules is significantly higher than that of invisible nodules. The traditional method of predicting the rEBUS-visibility of nodules is based on the CT-bronchus signs, but its effectiveness may be unsatisfactory. Objective: We innovate a valuable predictive model based on virtual bronchoscopic navigation to identify beforehand which PPNs are likely to be successfully visualized by rEBUS. The innovative predictor is the ratio of the size of lesions (S) to the shortest straight-line distance (D) from the terminal point of the virtual navigation path to the localization point of the nodule. Methods: This is a retrospective study. On the training dataset of 214 patients, a receiver operating characteristic curve was drawn to understand the utility of the predictive model and get the optimal cut-off points. Ninety-two cases were enrolled in the validation dataset to validate the external predictive accuracy of the predictor. Results: The optimal cut-off point of the curve was 1.84 with the Youden index of 0.65, at which point the area under the curve was 0.85 (95% CI: 0.76-0.95). The predictor has a good performance in the validation dataset with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 100%, 100%, 71%, and 87%, respectively. Conclusion: The S/D ratio is a valuable and innovative method to identify beforehand which PPNs are likely to be successfully visualized by rEBUS. If the S/D ratio of the nodule is greater than 1.84, it will be visualized by rEBUS.
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Affiliation(s)
- Hui Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Yiming Yu
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Xuechan Yu
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Sha Li
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Lin Zheng
- Department of Microbiology, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Shuya Zhang
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Qidong Zhuang
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China
| | - Zaichun Deng
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China,Zaichun Deng, Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, No.247, Renmin Road, Jiangbei District, Ningbo, Zhejiang Province, 315020, China.
| | - Zhongbo Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang Province, China,Zhongbo Chen, Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical School, Ningbo University, No.247, Renmin Road, Jiangbei District, Ningbo, Zhejiang Province, 315020, China.
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13
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Kramer T, Annema JT. Advanced bronchoscopic techniques for the diagnosis and treatment of peripheral lung cancer. Lung Cancer 2021; 161:152-162. [PMID: 34600406 DOI: 10.1016/j.lungcan.2021.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 12/14/2022]
Abstract
Lung cancer is the leading cause of cancer related deaths worldwide. As a result of the increasing use of chest CT scans and lung cancer screening initiatives, there is a rapidly increasing need for lung lesion analysis and - in case of confirmed cancer - treatment. A desirable future concept is the one-stop outpatient bronchoscopic approach including navigation to the tumor, malignancy confirmation and immediate treatment. Several novel bronchoscopic diagnostic and treatment concepts are currently under evaluation contributing to this concept. As the majority of suspected malignant lung lesions develop in the periphery of the lungs, improved bronchoscopic navigation to the target lesion is of key importance. Fortunately, the field of interventional pulmonology is evolving rapidly and several advanced bronchoscopic navigation techniques are clinically available, allowing an increasingly accurate tissue diagnosis of peripheral lung lesions. Additionally, multiple bronchoscopic treatment modalities are currently under investigation. This review will provide a concise overview of advanced bronchoscopic techniques to diagnose and treat peripheral lung cancer by describing their working mechanisms, strengths and weaknesses, identifying knowledge gaps and indicating future developments. The desired one-step concept of bronchoscopic 'diagnose and treat' peripheral lung cancer is on the horizon.
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Affiliation(s)
- Tess Kramer
- Department of Respiratory Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam UMC, Amsterdam, The Netherlands.
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14
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Zarogoulidis P, Matthaios D, Kosmidis C, Hohenforst-Schmidt W, Tsakiridis K, Mpaka S, Boukovinas I, Drougas D, Theofilatou V, Zaric B, Courcoutsakis N, Nikolaidis G, Huang H, Bai C. Effective early diagnosis for NSCLC: an algorithm. Expert Rev Respir Med 2021; 15:1437-1445. [PMID: 34403620 DOI: 10.1080/17476348.2021.1969916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Paul Zarogoulidis
- 3rd Department of Surgery, ``ahepa`` University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece.,Pulmonary Oncology Department, ``Bioclinic`` Private Hospital, Thessaloniki, Greece
| | | | | | - Wolfgang Hohenforst-Schmidt
- Sana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, "Hof" Clinics, University of Erlangen, Hof, Germany
| | - Kosmas Tsakiridis
- Thoracic Oncology Department, ``Interbalkan`` European Medical Center, Thessaloniki, Greece
| | - Sofia Mpaka
- Oncology Department, ``Interbalkan`` European Medical Center, Thessaloniki, Greece
| | - Ioannis Boukovinas
- Oncology Department, ``Bioclinic`` Private Hospital, Thessaloniki, Greece
| | - Dimitris Drougas
- Nuclear Medicine Department, ``Bioiatriki`` Private PET-CT Laboratory, Thessaloniki, Greece
| | - Vasiliki Theofilatou
- Nuclear Medicine Department, ``Bioiatriki`` Private PET-CT Laboratory, Thessaloniki, Greece
| | - Bojan Zaric
- Faculty of Medicine, University of Novi Sad, Institute for Pulmonary Diseases of Vojvodina, Novi Sad, Serbia
| | - Nikolaos Courcoutsakis
- Radiology Department, Democritus University of Thrace, General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George Nikolaidis
- Surgery Department, ``General Clinic`` Euromedica, Thessaloniki, Greece
| | - Haidong Huang
- Department of Respiratory & Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Chong Bai
- Department of Respiratory & Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai, China
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15
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[Expert Consensus on Technical Specifications of Domestic Electromagnetic Navigation Bronchoscopy System in Diagnosis, Localization and Treatment (2021 Edition)]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2021; 24:529-537. [PMID: 34412766 PMCID: PMC8387647 DOI: 10.3779/j.issn.1009-3419.2021.101.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Electromagnetic navigation bronchoscopy (ENB) is a novel type of bronchoscopy based on electromagnetic positioning technique combined with virtual bronchoscopy, three-dimensional computed tomography (CT) imaging and respiratory gating technique, which has been widely applied in clinic practice. In recent years, the domestic electromagnetic navigation system has also been developed rapidly, and its effectiveness and safety in the diagnosis, localization, and treatment of peripheral pulmonary lesions have been initially verified. In order to optimize and standardize the technical specifications of domestic ENB and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Respiratory Equipment Technology of Chinese Medical Equipment Association and the Expert Group on Technical of Domestic Electromagnetic Navigation Bronchoscopy.
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16
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Zheng X, Xie F, Li Y, Chen J, Jiang Y, Sun J. Ultrathin bronchoscope combined with virtual bronchoscopic navigation and endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions with or without fluoroscopy: A randomized trial. Thorac Cancer 2021; 12:1864-1872. [PMID: 33956409 PMCID: PMC8201532 DOI: 10.1111/1759-7714.13995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 11/27/2022] Open
Abstract
Background Transbronchial lung biopsy (TBLB) is usually performed to obtain a definitive diagnosis for peripheral pulmonary lesions (PPLs). Ultrathin bronchoscopy combined with virtual bronchoscopic navigation (VBN) and radial endobronchial ultrasound (R‐EBUS) are generally considered appropriate diagnostic methods for PPLs; however, they have not yet been explored in combination with fluoroscopy. Therefore, the present prospective randomized controlled trial determined the role of fluoroscopy in ultrathin bronchoscopy combined with VBN and R‐EBUS for the diagnosis of PPLs. Methods Patients with potentially malignant PPLs were enrolled in the study and randomized into fluoroscopy or nonfluoroscopy groups. In both groups, a 3.0‐mm outer and 1.7‐mm internal diameter ultrathin bronchoscope was used for transbronchial lung biopsy combined with R‐EBUS and VBN. In addition, the fluoroscopy group (FG) underwent fluoroscopy, while the nonfluoroscopy group (NFG) did not. Results A total of 126 patients were enrolled and randomized in the study. Among them, 120 patients (60 in the NFG and 60 in the FG) were analyzed. The mean lesion sizes were 26.3 ± 11.4 mm and 29.0 ± 11.3 mm in the NFG and FG, respectively. The diagnostic yield was 73.3% (44/60) in the NFG and 81.7% (49/60) in the FG without statistically significant difference (p = 0.38). No obvious complications occurred in either group. Conclusions Ultrathin bronchoscope combined with VBN and R‐EBUS without fluoroscopy is a feasible and safe diagnostic method for PPLs.
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Affiliation(s)
- Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Ying Li
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Yifeng Jiang
- Department of Radiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
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