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Ji T, Lin H, Liu R, Ma W, Wang Y, Hu Z, Li H. An alternative bronchoscopic transparenchymal nodule access by "invisible tunnel" technique under electromagnetic navigation without the transbronchial access tool. Eur J Med Res 2024; 29:406. [PMID: 39103884 PMCID: PMC11299338 DOI: 10.1186/s40001-024-02003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 07/30/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND The diagnosis of peripheral pulmonary lesions (PPL) is still challenging. We describe a novel method for sampling PPL without bronchial signs by creating invisible tunnel under electromagnetic navigation without the transbronchial access tool (TABT). METHODS During electromagnetic navigation, we adjust the angle of the edge extended working channel catheter based on the real-time position of the lesion in relation to the locating guide rather than preset route. A biopsy brush or biopsy forceps is used to punch a hole in the bronchial wall. A locating guide is then re-inserted to real-time navigate through the lung parenchyma to the lesion. Safety and feasibility of this method was analyzed. RESULTS A total of 32 patients who underwent electromagnetic navigation bronchoscopy were retrieved. The mean size of the lesion is 23.1 mm. The mean operative time of all patients was 12.4 min. Ten of the patients did not have a direct airway to the lesion, thus creating an invisible tunnel. For them, the length of the tunnel from the bronchial wall POE to the lesion was 11-30 mm, with a mean length of 16.9 mm and a mean operation time of 14.1 min. Adequate samples were obtained from 32 patients (100%), and the diagnostic yield was 87.5% (28/32). Diagnostic yield of with create the invisible tunnel TBAT was 90% (9/10), and one patient undergone pneumothorax after operation. CONCLUSIONS This method is feasible and safe as a novel approach sampling pulmonary lesions without bronchial signs, and it further improves current tunnel technique.
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Affiliation(s)
- Tingfen Ji
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
- Department of Respiratory and Critical Care Medicine, Lishui Hospital of Wenzhou Medical University,, 15# Dazhong Street, Liandu District, Lishui, Zhejiang, China
| | - Huihui Lin
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Rong Liu
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Wenjiang Ma
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Yuehong Wang
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Zhiqiang Hu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Hequan Li
- Department of Respiratory Diseases, The First Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang, China.
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2
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Corcoran A, Finn L, Piccione J, Phinizy P. Computed tomography navigation guided transparenchymal nodule biopsy in pediatric patients with pulmonary lesions. Pediatr Pulmonol 2024; 59:2012-2014. [PMID: 38578145 DOI: 10.1002/ppul.26999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/06/2024]
Affiliation(s)
- Aoife Corcoran
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Laura Finn
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph Piccione
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pelton Phinizy
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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3
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Shaller BD, Sethi S, Cicenia J. Imaging in peripheral bronchoscopy. Curr Opin Pulm Med 2024; 30:17-24. [PMID: 37933680 DOI: 10.1097/mcp.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Historically the sampling of peripheral lung lesions via bronchoscopy has suffered from inferior diagnostic outcomes relative to transthoracic needle aspiration, and neither a successful bronchoscopic navigation nor a promising radial ultrasonographic image of one's target lesion guarantees a successful biopsy. Fortunately, many of peripheral bronchoscopy's shortcomings - including an inability to detect and compensate for computed tomography (CT)-body divergence, and the absence of tool-in-lesion confirmation - are potentially remediable through the use of improved intraprocedural imaging techniques. RECENT FINDINGS Recent advances in intraprocedural imaging, including the integration of cone beam CT, digital tomosynthesis, and augmented fluoroscopy into bronchoscopic procedures have yielded promising results. These advanced imaging modalities may improve the outcomes of peripheral bronchoscopy through the detection and correction of navigational errors, CT-body divergence, and malpositioned biopsy instruments. SUMMARY The incorporation of advanced imaging is an essential step in the improvement of peripheral bronchoscopic procedures.
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Affiliation(s)
- Brian D Shaller
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonali Sethi
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Cicenia
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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4
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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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5
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Zhang Q, Wu X, Yang H, Sun Y, Wang Z, Yang L, Wei N, Zhang Y, Yang Y, Zhao X, Herth FJ, Zhang X. Bronchoscopic transparenchymal nodule access in the diagnosis and management of pulmonary nodules. Chin Med J (Engl) 2023:00029330-990000000-00604. [PMID: 37160736 DOI: 10.1097/cm9.0000000000002355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Indexed: 05/11/2023] Open
Affiliation(s)
- Quncheng Zhang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Xuan Wu
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Huizhen Yang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Ya Sun
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
- Xinxiang Medical University, Xinxiang, Henan 453003, China
| | - Ziqi Wang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Li Yang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Nan Wei
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Yihua Zhang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
- Xinxiang Medical University, Xinxiang, Henan 453003, China
| | - Yuanjian Yang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Xingru Zhao
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Felix Jf Herth
- Department of Pneumology and Respiratory Care Medicine, Thoraxklinik and Translational Lung Research Center, University of Heidelberg, Heidelberg D-69126, Germany
| | - Xiaoju Zhang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
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6
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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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7
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Vijayan R, Sheth N, Mekki L, Lu A, Uneri A, Sisniega A, Magaraggia J, Kleinszig G, Vogt S, Thiboutot J, Lee H, Yarmus L, Siewerdsen JH. 3D-2D image registration in the presence of soft-tissue deformation in image-guided transbronchial interventions. Phys Med Biol 2022; 68. [PMID: 36317269 DOI: 10.1088/1361-6560/ac9e3c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Purpose. Target localization in pulmonary interventions (e.g. transbronchial biopsy of a lung nodule) is challenged by deformable motion and may benefit from fluoroscopic overlay of the target to provide accurate guidance. We present and evaluate a 3D-2D image registration method for fluoroscopic overlay in the presence of tissue deformation using a multi-resolution/multi-scale (MRMS) framework with an objective function that drives registration primarily by soft-tissue image gradients.Methods. The MRMS method registers 3D cone-beam CT to 2D fluoroscopy without gating of respiratory phase by coarse-to-fine resampling and global-to-local rescaling about target regions-of-interest. A variation of the gradient orientation (GO) similarity metric (denotedGO') was developed to downweight bone gradients and drive registration via soft-tissue gradients. Performance was evaluated in terms of projection distance error at isocenter (PDEiso). Phantom studies determined nominal algorithm parameters and capture range. Preclinical studies used a freshly deceased, ventilated porcine specimen to evaluate performance in the presence of real tissue deformation and a broad range of 3D-2D image mismatch.Results. Nominal algorithm parameters were identified that provided robust performance over a broad range of motion (0-20 mm), including an adaptive parameter selection technique to accommodate unknown mismatch in respiratory phase. TheGO'metric yielded median PDEiso= 1.2 mm, compared to 6.2 mm for conventionalGO.Preclinical studies with real lung deformation demonstrated median PDEiso= 1.3 mm with MRMS +GO'registration, compared to 2.2 mm with a conventional transform. Runtime was 26 s and can be reduced to 2.5 s given a prior registration within ∼5 mm as initialization.Conclusions. MRMS registration via soft-tissue gradients achieved accurate fluoroscopic overlay in the presence of deformable lung motion. By driving registration via soft-tissue image gradients, the method avoided false local minima presented by bones and was robust to a wide range of motion magnitude.
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Affiliation(s)
- R Vijayan
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - N Sheth
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - L Mekki
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - A Lu
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - A Uneri
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - A Sisniega
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | | | | | - S Vogt
- Siemens Healthineers, Erlangen, Germany
| | - J Thiboutot
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, MD, United States of America
| | - H Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, MD, United States of America
| | - L Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, MD, United States of America
| | - J H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America.,Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
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8
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Giri M, Dai H, Puri A, Liao J, Guo S. Advancements in navigational bronchoscopy for peripheral pulmonary lesions: A review with special focus on virtual bronchoscopic navigation. Front Med (Lausanne) 2022; 9:989184. [PMID: 36300190 PMCID: PMC9588954 DOI: 10.3389/fmed.2022.989184] [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: 07/08/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Lung cancer is often diagnosed at an advanced stage and is associated with significant morbidity and mortality. Low-dose computed tomography for lung cancer screening has increased the incidence of peripheral pulmonary lesions. Surveillance and early detection of these lesions at risk of developing cancer are critical for improving patient survival. Because these lesions are usually distal to the lobar and segmental bronchi, they are not directly visible with standard flexible bronchoscopes resulting in low diagnostic yield for small lesions <2 cm. The past 30 years have seen several paradigm shifts in diagnostic bronchoscopy. Recent technological advances in navigation bronchoscopy combined with other modalities have enabled sampling lesions beyond central airways. However, smaller peripheral lesions remain challenging for bronchoscopic biopsy. This review provides an overview of recent advances in interventional bronchoscopy in the screening, diagnosis, and treatment of peripheral pulmonary lesions, with a particular focus on virtual bronchoscopic navigation.
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Affiliation(s)
- Mohan Giri
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyun Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Anju Puri
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiaxin Liao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Shuliang Guo
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9
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Kho SS, Nasaruddin MZ, Rahaman JAA. Virtual Bronchoscopic Navigation Guided Recanalization of Chronic Total Post-Tuberculosis Bronchial Stenosis. Arch Bronconeumol 2022; 58:768-769. [DOI: 10.1016/j.arbres.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 12/01/2022]
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10
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Garner JL, Shah PL. Bronchoscopic approaches to sampling lung nodules: Aiming for the bulls eye. Respirology 2022; 27:325-327. [PMID: 35315172 DOI: 10.1111/resp.14250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Justin L Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK.,Department of Respiratory Medicine, Chelsea & Westminster Hospital, London, UK
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11
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Sun J, Criner GJ, Dibardino D, Li S, Nader D, Lam B, Kopas L, Wahidi MM, Majid A, Marron R, Verga S, Herth FJF. Efficacy and safety of virtual bronchoscopic navigation with fused fluoroscopy and vessel mapping for access of pulmonary lesions. Respirology 2022; 27:357-365. [PMID: 35212090 DOI: 10.1111/resp.14224] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/20/2021] [Accepted: 01/20/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Virtual bronchoscopic navigation (VBN) with fused fluoroscopy and vessel mapping provides a point of entry (POE) for puncturing airway wall to biopsy lesions. The study was designed to evaluate the safety and efficacy of this technology to diagnose peripheral pulmonary lesions. METHODS It was a prospective, single-arm, multicentre study. Patients underwent lesions biopsy with the Archimedes® VBN System via a POE using one of the two techniques: (1) bronchoscopic transparenchymal nodule access (BTPNA) and (2) guided transbronchial needle aspiration (TBNA). Biopsy yield, sampling yield and diagnostic yield were mainly determined in lesions biopsy attempted. RESULTS One hundred and thirty patients underwent anaesthesia and constituted the intention-to-treat population. One hundred and four patients with 114 lesions had biopsy attempted. Mean lesion size was 2.4 ± 1.13 cm. Sufficient tissue samples were obtained from 86 lesions with a biopsy yield of 75.4%. Nevertheless, sufficient samples for diagnosis based on histology ± cytology were obtained from 107 lesions with a sampling yield of 93.9%. Follow-up was conducted for more than 1 year, with a diagnostic yield of 75.4% and 72.8%, respectively, on high and low estimate with consideration of three lesions without follow-up. Two (1.9%) pneumothoraxes and one (1.0%) mild bleeding occurred. CONCLUSION BTPNA and guided TBNA contribute to safe and effective sampling of peripheral pulmonary lesions. A relatively high biopsy yield was obtained independent of the presence or absence of a bronchus sign (BS), and high sampling yield and diagnostic yield were obtained independent of location, lesion size and presence or absence of a BS.
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Affiliation(s)
- Jiayuan Sun
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care Medicine, Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - David Dibardino
- Section of Interventional Pulmonology, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shiyue Li
- State Key Laboratory of Respiratory Disease, Guangzhou Respiratory Institute, Guangzhou, China
| | - Daniel Nader
- Interventional Pulmonology, Cancer Treatment Center of America, Tulsa, Oklahoma, USA
| | - Bing Lam
- Respiratory Medicine Center, Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - Lisa Kopas
- Pulmonary and Critical Care Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Momen M Wahidi
- Department of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Adnan Majid
- Department of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Marron
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Steven Verga
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Felix J F Herth
- Department of Pneumology and Respiratory Care Medicine, Thoraxklinik and Translational Lung Research Center, University of Heidelberg, Heidelberg, Germany
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12
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Levine MZ, Goodman S, Lentz RJ, Maldonado F, Rickman OB, Katsis J. Advanced Bronchoscopic Technologies for Biopsy of the Pulmonary Nodule: A 2021 Review. Diagnostics (Basel) 2021; 11:2304. [PMID: 34943541 PMCID: PMC8700532 DOI: 10.3390/diagnostics11122304] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/23/2021] [Accepted: 12/05/2021] [Indexed: 12/26/2022] Open
Abstract
The field of interventional pulmonology (IP) has grown from a fringe subspecialty utilized in only a few centers worldwide to a standard component in advanced medical centers. IP is increasingly recognized for its value in patient care and its ability to deliver minimally invasive and cost-effective diagnostics and treatments. This article will provide an in-depth review of advanced bronchoscopic technologies used by IP physicians focusing on pulmonary nodules. While most pulmonary nodules are benign, malignant nodules represent the earliest detectable manifestation of lung cancer. Lung cancer is the second most common and the deadliest cancer worldwide. Differentiating benign from malignant nodules is clinically challenging as these entities are often indistinguishable radiographically. Tissue biopsy is often required to discriminate benign from malignant nodule etiologies. A safe and accurate means of definitively differentiating benign from malignant nodules would be highly valuable for patients, and the medical system at large. This would translate into a greater number of early-stage cancer detections while reducing the burden of surgical resections for benign disease. There is little high-grade evidence to guide clinicians on optimal lung nodule tissue sampling modalities. The number of novel technologies available for this purpose has rapidly expanded over the last decade, making it difficult for clinicians to assess their efficacy. Unfortunately, there is a wide variety of methods used to determine the accuracy of these technologies, making comparisons across studies impossible. This paper will provide an in-depth review of available data regarding advanced bronchoscopic technologies.
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Affiliation(s)
- Micah Z. Levine
- Rush University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Rush University, Chicago, IL 60612, USA; (M.Z.L.); (S.G.)
| | - Sam Goodman
- Rush University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Rush University, Chicago, IL 60612, USA; (M.Z.L.); (S.G.)
| | - Robert J. Lentz
- Vanderbilt University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Vanderbilt University, Nashville, TN 37232, USA; (R.J.L.); (F.M.); (O.B.R.)
| | - Fabien Maldonado
- Vanderbilt University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Vanderbilt University, Nashville, TN 37232, USA; (R.J.L.); (F.M.); (O.B.R.)
| | - Otis B. Rickman
- Vanderbilt University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Vanderbilt University, Nashville, TN 37232, USA; (R.J.L.); (F.M.); (O.B.R.)
| | - James Katsis
- Rush University Medical Center, Department of Internal Medicine, Division of Pulmonary and Critical Care, Rush University, Chicago, IL 60612, USA; (M.Z.L.); (S.G.)
- Rush University Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Rush University, Chicago, IL 60612, USA
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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: 22] [Impact Index Per Article: 7.3] [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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Pertzov B, Gershman E, Izhakian S, Heching M, Amor SM, Rosengarten D, Kramer MR. The LungVision navigational platform for peripheral lung nodule biopsy and the added value of cryobiopsy. Thorac Cancer 2021; 12:2007-2012. [PMID: 34096182 PMCID: PMC8258356 DOI: 10.1111/1759-7714.14003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The LungVision system is a novel augmented-fluoroscopy-based real-time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real-time visualization and localization of pulmonary nodules. OBJECTIVES To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system. METHODS This prospective, single-center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy. RESULTS Sixty-three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18-28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported. CONCLUSIONS The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield.
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Affiliation(s)
- Barak Pertzov
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Evgeni Gershman
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shimon Izhakian
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Heching
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Moshe Amor
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Rosengarten
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Reuven Kramer
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Wagh A, Ho E, Murgu S, Hogarth DK. Improving diagnostic yield of navigational bronchoscopy for peripheral pulmonary lesions: a review of advancing technology. J Thorac Dis 2020; 12:7683-7690. [PMID: 33447461 PMCID: PMC7797818 DOI: 10.21037/jtd-2020-abpd-003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With recommendations for low dose CT scan for lung cancer screening, there has been an increase in the finding of lung nodules and peripheral pulmonary lesions (PPLs). Additionally, when there is concern for malignancy, guidelines have recommended performing the least invasive evaluation. Conventional bronchoscopy diagnostic yields for PPLs have reportedly been quite low and prior electromagnetic navigation bronchoscopy (ENB) studies have reported variable yields. Navigation bronchoscopy in addition to endobronchial ultrasound allows a physician to evaluate peripheral lung lesions along with mediastinal and hilar lymph nodes for the diagnosis and staging of suspected malignancy in one procedure. More recent advances in navigational bronchoscopy including the use of augmented fluoroscopy (AF), cone beam CT, and robotic bronchoscopy have pushed the boundaries of capability in evaluating PPLs. These added bronchoscopic technologies have shown to improve diagnostic yield especially when modalities are used in combination. The ultimate goal of endoscopically localized ablative and therapeutic treatment for peripheral lung lesions will require a high level of physician confidence, accuracy, and precision. This article will review the innovative characteristics and data of some of the more recently available navigational bronchoscopy devices.
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Affiliation(s)
- Ajay Wagh
- Section of Pulmonary and Critical Care Medicine/Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Elliot Ho
- Section of Pulmonary and Critical Care Medicine/Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Septimiu Murgu
- Section of Pulmonary and Critical Care Medicine/Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Douglas Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine/Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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16
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Kalsi HS, Thakrar R, Gosling AF, Shaefi S, Navani N. Interventional Pulmonology: A Brave New World. Thorac Surg Clin 2020; 30:321-338. [PMID: 32593365 DOI: 10.1016/j.thorsurg.2020.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Interventional pulmonology is a dynamic and evolving field in respiratory medicine. Advances have improved the ability to diagnose and manage diseases of the airways. A shift toward early detection of malignant disease has generated a focus on innovative diagnostic techniques. With patient populations living longer with malignant and benign diseases, the role for interventional bronchoscopy has grown. In cancer groups, novel immunotherapies have improved the prospects of clinical outcomes and reignited a focus on optimizing patient performance status to enable access to anticancer therapy. This review discusses current and emerging diagnostic modalities and therapeutic approaches available to manage airway diseases.
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Affiliation(s)
- Hardeep S Kalsi
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK
| | - Ricky Thakrar
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK
| | - Andre F Gosling
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, USA
| | - Neal Navani
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK.
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17
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Lam S, Bryant H, Donahoe L, Domingo A, Earle C, Finley C, Gonzalez AV, Hergott C, Hung RJ, Ireland AM, Lovas M, Manos D, Mayo J, Maziak DE, McInnis M, Myers R, Nicholson E, Politis C, Schmidt H, Sekhon HS, Soprovich M, Stewart A, Tammemagi M, Taylor JL, Tsao MS, Warkentin MT, Yasufuku K. Management of screen-detected lung nodules: A Canadian partnership against cancer guidance document. CANADIAN JOURNAL OF RESPIRATORY CRITICAL CARE AND SLEEP MEDICINE 2020. [DOI: 10.1080/24745332.2020.1819175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stephen Lam
- British Columbia Cancer Agency & the University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather Bryant
- Screening and Early Detection, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Ashleigh Domingo
- Screening and Early Detection, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Craig Earle
- Screening and Early Detection, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Christian Finley
- Department of Thoracic Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Anne V. Gonzalez
- Division of Respiratory Medicine, McGill University, Montreal, Quebec, Canada
| | - Christopher Hergott
- Division of Respiratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rayjean J. Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Anne Marie Ireland
- Patient and Family Advocate, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Michael Lovas
- Patient and Family Advocate, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Mayo
- Department of Radiology, Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donna E. Maziak
- Surgical Oncology Division of Thoracic Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Renelle Myers
- British Columbia Cancer Agency & the University of British Columbia, Vancouver, British Columbia, Canada
| | - Erika Nicholson
- Screening and Early Detection, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Christopher Politis
- Screening and Early Detection, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Heidi Schmidt
- University Health Network and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Harman S. Sekhon
- Department of Pathology and Laboratory Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marie Soprovich
- Patient and Family Advocate, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Archie Stewart
- Patient and Family Advocate, Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Martin Tammemagi
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Jana L. Taylor
- Department of Radiology, McGill University, Montreal, Quebec, Canada
| | - Ming-Sound Tsao
- Department of Laboratory Medicine and Pathobiology, University Health Network and Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Matthew T. Warkentin
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Department of Surgery and Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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18
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Sebek J, Kramer S, Rocha R, Yu KC, Bortel R, Beard WL, Biller DS, Hodgson DS, Ganta CK, Wibowo H, Yee J, Myers R, Lam S, Prakash P. Bronchoscopically delivered microwave ablation in an in vivo porcine lung model. ERJ Open Res 2020; 6:00146-2020. [PMID: 33083442 PMCID: PMC7553114 DOI: 10.1183/23120541.00146-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/06/2020] [Indexed: 02/06/2023] Open
Abstract
Background Percutaneous microwave ablation is clinically used for inoperable lung tumour treatment. Delivery of microwave ablation applicators to tumour sites within lung parenchyma under virtual bronchoscopy guidance may enable ablation with reduced risk of pneumothorax, providing a minimally invasive treatment of early-stage tumours, which are increasingly detected with computed tomography (CT) screening. The objective of this study was to integrate a custom microwave ablation platform, incorporating a flexible applicator, with a clinically established virtual bronchoscopy guidance system, and to assess technical feasibility for safely creating localised thermal ablations in porcine lungs in vivo. Methods Pre-ablation CTs of normal pigs were acquired to create a virtual model of the lungs, including airways and significant blood vessels. Virtual bronchoscopy-guided microwave ablation procedures were performed with 24–32 W power (at the applicator distal tip) delivered for 5–10 mins. A total of eight ablations were performed in three pigs. Post-treatment CT images were acquired to assess the extent of damage and ablation zones were further evaluated with viability stains and histopathologic analysis. Results The flexible microwave applicators were delivered to ablation sites within lung parenchyma 5–24 mm from the airway wall via a tunnel created under virtual bronchoscopy guidance. No pneumothorax or significant airway bleeding was observed. The ablation short axis observed on gross pathology ranged 16.5–23.5 mm and 14–26 mm on CT imaging. Conclusion We have demonstrated the technical feasibility for safely delivering microwave ablation in the lung parenchyma under virtual bronchoscopic guidance in an in vivo porcine lung model. This paper demonstrates the technical feasibility of safely delivering microwave ablation in the lung parenchyma under virtual bronchoscopic guidance in an in vivo porcine lung modelhttps://bit.ly/32aruLf
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Affiliation(s)
- Jan Sebek
- Dept of Electrical and Computer Engineering, Kansas State University Manhattan, Manhattan, KS, USA.,Dept of Circuit Theory, Czech Technical University in Prague, Prague, Czech Republic
| | | | - Rob Rocha
- Broncus Medical, Inc., San Jose, CA, USA
| | | | - Radoslav Bortel
- Dept of Circuit Theory, Czech Technical University in Prague, Prague, Czech Republic
| | - Warren L Beard
- Dept of Clinical Sciences, Kansas State University, Manhattan, KS, USA
| | - David S Biller
- Dept of Clinical Sciences, Kansas State University, Manhattan, KS, USA
| | - David S Hodgson
- Dept of Clinical Sciences, Kansas State University, Manhattan, KS, USA
| | - Charan K Ganta
- Dept of Diagnostic Medicine/Pathobiology, Kansas State University, Manhattan, KS, USA
| | | | - John Yee
- Dept of Thoracic Surgery, Vancouver General Hospital and the University of British Columbia, Vancouver, Canada
| | - Renelle Myers
- Dept of Thoracic Surgery, Vancouver General Hospital and the University of British Columbia, Vancouver, Canada.,Dept of Integrative Oncology, BC Cancer Research Center and the University of British Columbia, Vancouver, Canada
| | - Stephen Lam
- Dept of Integrative Oncology, BC Cancer Research Center and the University of British Columbia, Vancouver, Canada
| | - Punit Prakash
- Dept of Electrical and Computer Engineering, Kansas State University Manhattan, Manhattan, KS, USA
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19
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Criner GJ, Eberhardt R, Fernandez-Bussy S, Gompelmann D, Maldonado F, Patel N, Shah PL, Slebos DJ, Valipour A, Wahidi MM, Weir M, Herth FJ. Interventional Bronchoscopy. Am J Respir Crit Care Med 2020; 202:29-50. [PMID: 32023078 DOI: 10.1164/rccm.201907-1292so] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.
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Affiliation(s)
- Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | - Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Fabien Maldonado
- Department of Medicine and Department of Thoracic Surgery, Vanderbilt University, Nashville, Tennessee
| | - Neal Patel
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pallav L Shah
- Respiratory Medicine at the Royal Brompton Hospital and National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Krankenhaus Nord, Vienna, Austria; and
| | - Momen M Wahidi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mark Weir
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Felix J Herth
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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20
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Pritchett MA, Bhadra K, Calcutt M, Folch E. Virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy. J Thorac Dis 2020; 12:1595-1611. [PMID: 32395297 PMCID: PMC7212155 DOI: 10.21037/jtd.2020.01.35] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Guided bronchoscopy offers a minimally invasive and safe method for accessing indeterminate pulmonary nodules. However, all current guided bronchoscopy systems rely on a preprocedural computed tomography (CT) scan to create a virtual map of the patient's airways. Changes in lung anatomy between the preprocedural CT scan and the bronchoscopy procedure can lead to a divergence between the expected and actual location of the target lesion. Termed "CT-to-body divergence", this effect reduces diagnostic yield, adds time to the procedure, and can be challenging for the operator. The objective of this paper is to describe the concept of CT-to-body divergence, its contributing factors, and methods and technologies that might minimize its deleterious effects on diagnostic yield.
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Affiliation(s)
- Michael A Pritchett
- FirstHealth of the Carolinas and Pinehurst Medical Clinic, Pinehurst, NC, USA
| | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN, USA
| | - Mike Calcutt
- Clinical Education, Medtronic, Minneapolis, MN, USA
| | - Erik Folch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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21
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Computed Tomography Bronchus Sign and the Diagnostic Yield of Guided Bronchoscopy for Peripheral Pulmonary Lesions. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2019; 15:978-987. [PMID: 29877715 DOI: 10.1513/annalsats.201711-856oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Indeterminate peripheral pulmonary lesions (PPLs) often require tissue diagnosis. If nonsurgical biopsy techniques are considered, deciding between bronchoscopic transbronchial versus computed tomography-guided transthoracic biopsy can be difficult. The former has a low diagnostic yield with a low complication risk, whereas the latter has a better diagnostic yield but a higher complication rate. Investigators have looked at various lesion characteristics that can predict the diagnostic yield of guided bronchoscopic biopsies. Although consensus exists that larger size and proximity to the hilum increase the diagnostic yield, there is ongoing debate about the association between computed tomography bronchus sign (air-filled bronchus in close proximity of the lesion as seen on computed tomography imaging) and the diagnostic yield of guided bronchoscopic modalities. OBJECTIVES To perform a meta-analysis and systematic review, determining the association between computed tomography bronchus sign and the diagnostic yield of guided bronchoscopy for PPLs. METHODS MEDLINE, Embase, Scopus, and Google Scholar were searched in January 2018 for guided bronchoscopy studies that had assessed the impact of computed tomography bronchus sign on the diagnostic yield. The quality of included studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 tool. Meta-analysis was performed using MedCalc (version 18). Odds ratios were used to compare yield of lesions with and without bronchus sign. Random effects model was used when significant heterogeneity was observed (I2 > 40%). RESULTS For 2,199 lesions with computed tomography bronchus sign, the overall weighted diagnostic yield was 74.1% (95% confidence interval, 68.3-79.5%). For 971 lesions without computed tomography bronchus sign, the overall weighted diagnostic yield was 49.6% (95% confidence interval, 39.6-59.5%). The odds ratio for successfully diagnosing a lesion with computed tomography bronchus sign was 3.4 (95% confidence interval, 2.4-5.0). Possible sources of heterogeneity in the meta-analysis included differences in study designs, guidance modalities, and cancer prevalence. The odds ratio for successfully diagnosing a lesion with computed tomography bronchus sign was relatively lower for prospective studies. CONCLUSIONS PPLs with computed tomography bronchus sign are more likely to be diagnosed with guided bronchoscopy than the lesions without computed tomography bronchus sign. Clinicians should consider this, along with the lesion size and distance from the hilum, when contemplating guided bronchoscopy for PPLs.
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22
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Bronchoscopic navigation and tissue diagnosis. Gen Thorac Cardiovasc Surg 2019; 68:672-678. [PMID: 31686295 DOI: 10.1007/s11748-019-01241-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 12/12/2022]
Abstract
Diagnosis of early-stage lung cancer has become increasingly important as the detection of peripheral pulmonary lesions (PPLs) grows with widespread adoption of CT-based lung cancer screening. Although CT-guided transthoracic needle aspiration has been the standard diagnostic approach for PPLs, transbronchial sampling by bronchoscopy is often performed due to its reduced rate of adverse events. However, the diagnostic yield of conventional bronchoscopy is often poor. Various bronchoscopic technologies have emerged over recent years to address this limitation, including thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), virtual navigation bronchoscopy (VBN), electromagnetic navigation bronchoscopy (ENB), and robotic bronchoscopy. Bronchoscopic transparenchymal nodule access (BTPNA) and transbronchial access tool (TBAT) are novel techniques that leverage navigational bronchoscopic technologies to further improve access to lesions throughout the lung. The devices used for sampling tissue have similarly evolved, such as the introduction of cryobiopsy. These innovative bronchoscopic techniques allows higher diagnostic yield even in small PPLs. Given the complexity of these new techniques and technologies, it is important for physicians to understand their strengths and limitations.
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Abstract
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.
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Affiliation(s)
- Samuel Victor Kemp
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom, .,National Heart and Lung Institute, Imperial College, London, United Kingdom,
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24
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Ishiwata T, Gregor A, Inage T, Yasufuku K. Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions. Expert Rev Respir Med 2019; 13:885-897. [PMID: 31322455 DOI: 10.1080/17476348.2019.1645600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: The incidence of peripheral pulmonary lesions (PPLs) is growing following the adoption of lung cancer screening by low-dose chest CT. Although CT-guided transthoracic needle aspiration has been the standard method to diagnose PPLs, the field of interventional bronchoscopy is rapidly advancing to overcome complications of the transthoracic approach yet maintain the yield. Areas covered: This article reviews the clinical evidence of recent emerging interventional bronchoscopic techniques for diagnosis of PPLs. Expert opinion: Recent advances in interventional bronchoscopy contribute to not only the safety of transbronchial approaches to PPLs but also the higher diagnostic yield. To perform accurate sampling of PPLs, bronchoscopists must select the correct airway, approach the target as close as possible, and confirm the location of the target before sampling. These key steps can be assisted by recently developed technologies. However, it is important for bronchoscopists to understand the strengths and limitations of these emerging technologies.
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Affiliation(s)
- Tsukasa Ishiwata
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto , Toronto , Canada
| | - Alexander Gregor
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto , Toronto , Canada
| | - Terunaga Inage
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto , Toronto , Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto , Toronto , Canada
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Abstract
Much has changed since the last review of interventional pulmonology (IP) published in this Clinics series. The rate of development of new techniques and their complexities require IP physicians to be constantly maintaining and updating their skill set. International agreed training pathways help ensure that the interventionalists of the present and future have the required knowledge of anatomy, manual dexterity, and clinical judgment to keep up with the continuing advances that are constantly expanding IP's diagnostic and therapeutic boundaries. IP remains one of the most desirable subspecialities in pulmonology, and the technologic advances make the future an exciting one.
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Affiliation(s)
- Alastair J Moore
- Oxford Interventional Pulmonology, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Rachel M Mercer
- Oxford Interventional Pulmonology, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK; Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK
| | - Ali I Musani
- Interventional Pulmonology, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, University of Colorado School of Medicine, Denver, Academic Office 1, 12631 East 17th Avenue, M/S C323, Office # 8102, Aurora, CO 80045, USA.
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26
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Abstract
Current advances in guided bronchoscopy methods permit minimally invasive access to essentially any area of the lungs. This provides a potential means to treat patients with localized lung malignancies who might not otherwise tolerate conventional treatment, which commonly relies on surgical resection. Ablation methods have long been used for bronchoscopic treatment of central airway malignancies and percutaneous treatment of peripheral lung cancer. This article reviews ablation technologies being adapted for use with guided bronchoscopy and the current state of investigation for the treatment of peripheral lung malignancies.
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Affiliation(s)
- David W Hsia
- Division of Respiratory and Critical Care Physiology and Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, Box #402, Torrance, CA 90502, USA.
| | - Ali I Musani
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine and University Hospital, 12631 East 17th Avenue, M/S C323, Office #8102, Aurora, CO 80045, USA
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27
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Mallow C, Lee H, Oberg C, Thiboutot J, Akulian J, Burks AC, Luna B, Benzaquen S, Batra H, Cardenas-Garcia J, Toth J, Heidecker J, Belanger A, McClune J, Osman U, Lakshminarayanan V, Pastis N, Silvestri G, Chen A, Yarmus L. Safety and diagnostic performance of pulmonologists performing electromagnetic guided percutaneous lung biopsy (SPiNperc). Respirology 2019; 24:453-458. [PMID: 30675961 DOI: 10.1111/resp.13471] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Percutaneous lung biopsy for diagnostic sampling of peripheral lung nodules has been widely performed by interventional radiologists under computed tomography (CT) guidance. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. With the adoption of this new technique, the safety, feasibility and diagnostic yield need to be explored. The goal of this study was to determine the safety, feasibility and diagnostic yield of EM-guided percutaneous lung biopsy performed by pulmonologists. METHODS We conducted a retrospective, multicentre study of 129 EM-guided percutaneous lung biopsies that occurred between November 2013 and March 2017. The study consisted of seven academic and three community medical centres. RESULTS The average age of participants was 65.6 years, BMI was 26.3 and 50.4% were females. The majority of lesions were in the right upper lobe (37.2%) and left upper lobe (31.8%). The mean size of the lesions was 27.31 mm and the average distance from the pleura was 13.2 mm. Practitioners averaged two fine-needle aspirates and five core biopsies per procedure. There were 23 (17.8%) pneumothoraces, of which 16 (12.4%) received small-bore chest tube placement. The diagnostic yield of percutaneous lung biopsy was 73.7%. When EM-guided bronchoscopic sampling was also performed during the same procedural encounter, the overall diagnostic yield increased to 81.1%. CONCLUSION In this large multicentred series, the use of EM guidance for percutaneous lung biopsies was safe and feasible, with acceptable diagnostic yield in the hands of pulmonologists. A prospective multicentre trial to validate these findings is currently underway (NCT03338049).
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Affiliation(s)
- Christopher Mallow
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hans Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine Oberg
- Division of Pulmonary and Critical Care Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Thiboutot
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Allen C Burks
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Branden Luna
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Sadia Benzaquen
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hitesh Batra
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Jose Cardenas-Garcia
- Division of Pulmonary and Critical Care Medicine, University of Michigan School, Ann Arbor, MI, USA
| | - Jennifer Toth
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jay Heidecker
- Division of Pulmonary Medicine, Birmingham Pulmonary Group, Birmingham, AL, USA
| | - Adam Belanger
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jason McClune
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Umar Osman
- Division of Pulmonary and Critical Care Medicine, Memorial Health System, Marietta, OH, USA
| | - Venkatesh Lakshminarayanan
- Division of Pulmonary and Critical Care Medicine, Pulmonary and Critical Care of Atlanta, Atlanta, GA, USA
| | - Nicholas Pastis
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Gerard Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander Chen
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Diez-Ferrer M, Morales A, Tebé C, Cubero N, López-Lisbona R, Padrones S, Aso S, Dorca J, Gil D, Rosell A. Ultrathin Bronchoscopy with and without Virtual Bronchoscopic Navigation: Influence of Segmentation on Diagnostic Yield. Respiration 2018; 97:252-258. [DOI: 10.1159/000493270] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/23/2018] [Indexed: 11/19/2022] Open
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Lerner AD, Feller-Kopman D. Is bronchoscopic treatment of lung cancer possible? Expert Rev Respir Med 2018; 13:1-3. [DOI: 10.1080/17476348.2019.1549493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Andrew D. Lerner
- Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Feller-Kopman
- Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sobieszczyk MJ, Yuan Z, Li W, Krimsky W. Biopsy of peripheral lung nodules utilizing cone beam computer tomography with and without trans bronchial access tool: a retrospective analysis. J Thorac Dis 2018; 10:5953-5959. [PMID: 30505506 DOI: 10.21037/jtd.2018.09.16] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Currently there are several techniques for endoscopic diagnosis of parenchymal lung abnormalities. Electromagnetic navigation with or without endobronchial ultrasound for diagnosis of the above has been well described. Bronchoscopic Trans Bronchial Access Tool is a novel endoscopic technique that creates a virtual pathway to the lesion and is less limited by location of the airway. The CrossCountryTM Transbronchial Access Tool (CovidienTM, Plymouth, MN, USA) is a Food and Drug Administration (FDA) approved off airway device that utilizes a catheter equipped guide sheath for a trans-parenchymal approach to a distal lesion. Cone beam computer tomography (CBCT) is a real-time onsite extrathoracic navigational modality used in the bronchoscopy suite that allows for an open working channel. All three of the above modalities can have reasonable diagnostic yields when used independently. While utilizing the above tools we frequently found ourselves in situations where one technique was not enough, prompting the use of a combination of modalities to obtain the most efficient and accurate diagnosis. We are reporting the feasibility and safety of utilizing these three modalities in conjunction with one another. Methods Patients with peripheral pulmonary nodules on chest computed tomography underwent a navigation bronchoscopy under general anesthesia. CBCT and radial ultrasound was used in every case to confirm navigation to the target lesion. Lesions without definitive airways leading to them were accessed with the transbronchial access tool (TBAT). Results Electromagnetic bronchoscopy using CBCT and radial US was performed on 22 patients from April 2016 to September 2016. The TBAT tool was used in 7 patients. The overall diagnostic yield was 77.2% (17 of 22). Diagnostic yield of with use TBAT was 100% (7 of 7). There were no complications. Average case length was 79.95 (range, 50-124) minutes and average fluoroscopy time was 10.39 (1-21.7) minutes. Conclusions TBAT is a useful and safe tool when accessing peripheral pulmonary nodules and is used in conjunctions with electromagnetic navigation and CBCT.
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Affiliation(s)
- Michal Jan Sobieszczyk
- Department of Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Zhuhui Yuan
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Wei Li
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - William Krimsky
- Department of Pulmonary and Critical Care Medicine, MedStar Franklin Square Medical Center, Baltimore, USA
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Krimsky WS, Pritchett MA, Lau KKW. Towards an optimization of bronchoscopic approaches to the diagnosis and treatment of the pulmonary nodules: a review. J Thorac Dis 2018; 10:S1637-S1644. [PMID: 30034829 DOI: 10.21037/jtd.2018.04.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The last several years have seen substantive improvements and innovation with respect to bronchoscopic approaches to the indeterminate pulmonary nodule both diagnostically and therapeutically. Indeed, these advances have only accelerated over the last year or two and extend across multiple domains and include improvements in imaging technologies and techniques, approaches and tools to access different areas of the lung, tools to acquire tissue as well as tools and methods to ablate tissue. Needless to say, there are a variety of different approaches in terms of how these issues are being solved along with differing levels of technology and infrastructure commitments necessary to utilize these various tools, with some of these approaches being farther along than others. This article reviews some of these recent advances in the domains of advanced imaging, approaches to accessing various parts of the lung, tools designed to acquire tissue, robotic endoscopy platforms, new approaches to tissue ablation as well as potential additions to these areas that are on the horizon.
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Affiliation(s)
- William S Krimsky
- Interventional Pulmonary Medicine, Medstar Franklin Square Medical Center, Baltimore, USA
| | - Michael A Pritchett
- Department of Pulmonary Medicine, Chest Center of the Carolinas, FirstHealth Moore Regional Hospital, Pinehurst Medical Clinic, Pinehurst, North Carolina, USA
| | - Kelvin K W Lau
- Department of Thoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, UK
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Escarguel B. Utilisation de l’échographie endobronchique dans les lésions pulmonaires distales. Rev Mal Respir 2018; 35:571-573. [DOI: 10.1016/j.rmr.2017.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
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Interventional Pulmonology and Solitary Pulmonary Nodule. Arch Bronconeumol 2018; 54:497-498. [PMID: 29580566 DOI: 10.1016/j.arbres.2018.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 12/20/2022]
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Goag EK, Lee JM, Chung KS, Kim SY, Leem AY, Song JH, Jung JY, Park MS, Chang YS, Kim YS, Chang J, Kim EY. Usefulness of Bronchoscopic Rebiopsy of Non-Small Cell Lung Cancer with Acquired Resistance to Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor. J Cancer 2018; 9:1113-1120. [PMID: 29581791 PMCID: PMC5868179 DOI: 10.7150/jca.21650] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Approximately 50% of non-small cell lung cancer (NSCLC) patients with acquired resistance to EGFR-TKI harbor the EGFR mutation T790M. The recent development and wide use of third-generation EGFR-TKIs targeting T790M-mutant NSCLCs have increased the importance of rebiopsy after EGFR-TKI failure. We aimed to investigate the advantages of flexible bronchoscopy as a rebiopsy method and the prevalence of and factors affecting the T790M mutation after EGFR-TKI failure. Methods: We investigated 139 patients who had undergone bronchoscopic rebiopsy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) between Sep 2014 and Jul 2016. Results: Among the 139 patients, bronchoscopic rebiopsy yielded successful pathological diagnoses in 102 (73.4%). Among them, 41 patients with EGFR-mutant lung adenocarcinoma and EGFR-TKI progression were selected for an investigation of T790M mutation prevalence at rebiopsy. The initial EGFR mutations were exon 19 del (56.1%), L858R or L861Q (34.1%), and others (9.8%). The most common rebiopsy method was transbronchial lung biopsy (41.5%), followed by EBUS-TBNA (26.8%) and endobronchial biopsy (19.5%). The median interval to T790M emergence was the longest among cases with exon 19 deletion (14.1 months), followed by exon 21 L858R or L861Q (11.3 months) and other rare EGFR mutations (2.9 months). The T790M mutation was identified in 18 (43.9%) patients, and exon 19 del was the most significant factor affecting T790M mutation development (hazard ratio: 6.875, P = 0.014). Conclusions: Bronchoscopy was more useful than other rebiopsy approaches. The T790M emergence rate was highest in cases with exon 19 deletion, likely as a consequence of long-term EGFR-TKI exposure.
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Affiliation(s)
- Eun Kyong Goag
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Mo Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Soo Chang
- Division of Pulmonology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Abstract
Peripheral pulmonary lesions (PPLs) are generally considered as lesions in the peripheral one-third of the lung although a precise definition and radiographic anatomical landmarks separating central and peripheral lesion does not yet exist. The radiographic detection of such lesions has increased significantly with the adoption of lung cancer screening programs. These lesions are not directly visible by regular flexible bronchoscopes as they are usually distal to the lobar and segmental bronchi. Traditionally, depending on location and clinical stage at presentation, these lesions were typically sampled by computerized tomography (CT) guided needle or surgical biopsy although some centers also used ultrasound and fluoroscopy guided percutaneous needle biopsy. Due to lack of direct visualization, the yield for bronchoscopic guided sampling especially of the small <2 cm pulmonary nodules was very low. Therefore, sampling has been preferentially performed by percutaneous CT guidance, which had high yield of above 90% but it comes at the cost of higher risk complications like pneumothorax with reported rate of 15% to 28%. Directly proceeding to surgical resection is also considered in appropriate candidates with high suspicion of malignancy without any evidence of distant metastasis but the proportion of such cases of lung cancer is low. The manuscript discussed the various bronchoscopic diagnostic modalities for peripheral pulmonary lesions. It is important to note that most of the studies in this field are relatively small, not randomized, suffer from selection bias, have considerable heterogeneity in sampling methodology/instruments and usually have been performed in high volume institutions by dedicated highly experienced proceduralists. The prevalence of malignancy in most of the reported cohorts has also been high which may result in higher diagnostic yields. All these factors need to be kept in mind before generalizing the results to individual centers and practices.
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Affiliation(s)
- Samjot Singh Dhillon
- Division of Pulmonary Medicine and Interventional Pulmonology, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kassem Harris
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Westchester Medical Center, Valhalla, NY, USA
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Belanger AR, Akulian JA. An update on the role of advanced diagnostic bronchoscopy in the evaluation and staging of lung cancer. Ther Adv Respir Dis 2017; 11:211-221. [PMID: 28470104 PMCID: PMC5933547 DOI: 10.1177/1753465817695981] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Lung cancer remains a common and deadly disease. Many modalities are available to
the bronchoscopist to evaluate and stage lung cancer. We review the role of
bronchoscopy in the staging of the mediastinum with convex endobronchial
ultrasound (EBUS) and discuss emerging role of esophageal ultrasonography as a
complementary modality. In addition, we discuss advances in scope technology and
elastography. We review the bronchoscopic methods available for the diagnosis of peripheral
lung nodules including radial EBUS and navigational bronchoscopy (NB) with a
consideration of the basic methodologies and diagnostic accuracies. We conclude
with a discussion of the comparison of the various methodologies.
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Affiliation(s)
- Adam R Belanger
- Division of Pulmonary and Critical Care, Section of Interventional Pulmonology, University of North Carolina at Chapel Hill, NC, USA
| | - Jason A Akulian
- Assistant Professor of Medicine, Director, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, 8007 Burnett Womack Bldg., CB 7219, Chapel Hill, NC 27713, USA
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