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Beqari J, Hurd J, Masaki F, Tfayli B, Kharroubi H, Naito M, King F, Colson Y. Assessing the accuracy of a multisection robotic bronchoscope prototype in localization and targeting of small pulmonary lesions. JTCVS Tech 2024; 26:112-120. [PMID: 39156546 PMCID: PMC11329203 DOI: 10.1016/j.xjtc.2024.05.011] [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: 05/02/2023] [Revised: 04/30/2024] [Accepted: 05/10/2024] [Indexed: 08/20/2024] Open
Abstract
Objectives Robotic bronchoscopy (RB) has emerged as a novel technique to address issues with the biopsy of small peripheral lung lesions. The objective of this study was to quantitatively assess the accuracy of a novel multisection robotic bronchoscope compared with current standards of care. Methods This is a prospective, single-blind, comparative study where the accuracy of a multisection RB was compared against the accuracy of standard electromagnetic navigational bronchoscopy (EM-NB) during lesion localization and targeting. Five blinded subjects of varying bronchoscopy experience were recruited to use both RB and EM-NB in a swine lung model. Accuracy of localization and targeting success was measured as the distance from the center of pulmonary targets at each anatomic location. Subjects used both RB and EM-NB to navigate to 4 pulmonary targets assigned using 1:1 block randomization. Differences in accuracy and time between navigation systems were assessed using Wilcoxon rank-sum test. Results Of the 40 total attempts per modality, successful targeting was achieved on 90% and 85% of attempts utilizing RB and EM-NB, respectively. Furthermore, RB demonstrated significantly lower median distance to the real-time EM target (1.1 mm; interquartile range [IQR], 0.6-2.0 mm) compared with EM-NB (2.6 mm; IQR, 1.6-3.8) (P < .001). Median target displacement resulting from lung and bronchus deformation during bronchoscopy was found to be significantly lower using RB (0.8 mm; IQR, 0.5-1.2 mm) compared with EM-NB (2.6 mm; IQR, 1.4-6.4 mm) (P < .001). Conclusions The results of this study demonstrate that the multi-section RB prototype allows for improved localization and targeting of small peripheral lung nodules compared with current nonrobot bronchoscopy modalities.
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Affiliation(s)
- Jorind Beqari
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jacob Hurd
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Fumitaro Masaki
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
- Collaborative Innovation Center, Canon Medical Research USA, Inc, Cambridge, Mass
| | - Bassel Tfayli
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Hussein Kharroubi
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Masahito Naito
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Franklin King
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Yolonda Colson
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Copeland J, Rojas-Alexandre M, Tsai L, King F, Hata N. Characterizing the accuracy of robotic bronchoscopy in localization & targeting of small pulmonary lesions. Int J Comput Assist Radiol Surg 2024; 19:1505-1515. [PMID: 38890223 DOI: 10.1007/s11548-024-03152-9] [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: 05/10/2023] [Accepted: 04/15/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Considering the recent implementation of lung cancer screening guidelines, it is crucial that small pulmonary nodules are accurately diagnosed. There is a significant need for quick, precise, and minimally invasive biopsy methods, especially for patients with small lung lesions in the outer periphery. Robotic bronchoscopy (RB) has recently emerged as a novel solution. The purpose of this study was to evaluate the accuracy of RB compared to the existing standard, electromagnetic navigational bronchoscopy (EM-NB). METHODS A prospective, single-blinded, and randomized-controlled study was performed to compare the accuracy of RB to EM-NB in localizing and targeting pulmonary lesions in a porcine lung model. Four operators were tasked with navigating to four pulmonary targets in the outer periphery of a porcine lung, to which they were blinded, using both the RB and EM-NB systems. The dependent variable was accuracy. Accuracy was measured as a rate of success in lesion localization and targeting, the distance from the center of the pulmonary target, and by anatomic location. The independent variable was the navigation system, RB was compared to EM-NB using 1:1 randomization. RESULTS Of 75 attempts, 72 were successful in lesion localization and 60 were successful in lesion targeting. The success rate for lesion localization was 100% with RB and 91% with EM- NB. The success rate for lesion targeting was 93% with RB and 80% for EM-NB. RB demonstrated superior accuracy in reaching the distance from the center of the lesion, at 0.62 mm compared to EM-NB at 1.28 mm (p = 0.001). Accuracy was improved using RB compared to EM- NB for lesions in the LLL (p = 0.025), LUL (p < 0.001), and RUL (p < 0.001). CONCLUSION Our findings support RB as a more accurate method of navigating and localizing small peripheral pulmonary targets when compared to standard EM-NB in a porcine lung model. This may be attributed to the ability of RB to reduce substantial tissue displacement seen with standard EM-NB navigation. As the development and application of RB advances, so will the ability to accurately diagnose small peripheral lung cancer nodules, providing patients with early-stage lung cancer the best possible outcomes.
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Affiliation(s)
- Jessica Copeland
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mehida Rojas-Alexandre
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lilian Tsai
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Franklin King
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nobuhiko Hata
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Matsumoto Y, Kho SS, Furuse H. Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions. Expert Rev Respir Med 2024; 18:581-595. [PMID: 39093300 DOI: 10.1080/17476348.2024.2387089] [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: 03/08/2024] [Revised: 05/08/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined. AREAS COVERED This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed. EXPERT OPINION The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.
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Affiliation(s)
- Yuji Matsumoto
- Department of Endoscopy, Respiratory Endoscopy Division/Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Sze Shyang Kho
- Division of Respiratory Medicine, Department of Internal Medicine, Sarawak General Hospital, Kuching, Malaysia
| | - Hideaki Furuse
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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Shaller BD, Duong DK, Swenson KE, Free D, Bedi H. Added Value of a Robotic-assisted Bronchoscopy Platform in Cone Beam Computed Tomography-guided Bronchoscopy for the Diagnosis of Pulmonary Parenchymal Lesions. J Bronchology Interv Pulmonol 2024; 31:e0971. [PMID: 38953732 DOI: 10.1097/lbr.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/18/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Cone beam computed tomography (CBCT)-guided bronchoscopic sampling of peripheral pulmonary lesions (PPLs) is associated with superior diagnostic outcomes. However, the added value of a robotic-assisted bronchoscopy platform in CBCT-guided diagnostic procedures is unknown. METHODS We performed a retrospective review of 100 consecutive PPLs sampled using conventional flexible bronchoscopy under CBCT guidance (FB-CBCT) and 100 consecutive PPLs sampled using an electromagnetic navigation-guided robotic-assisted bronchoscopy platform under CBCT guidance (RB-CBCT). Patient demographics, PPL features, procedural characteristics, and procedural outcomes were compared between the 2 cohorts. RESULTS Patient and PPL characteristics were similar between the FB-CBCT and RB-CBCT cohorts, and there were no significant differences in diagnostic yield (88% vs. 90% for RB-CBCT, P=0.822) or incidence of complications between the 2 groups. As compared with FB-CBCT cases, RB-CBCT cases were significantly shorter (median 58 min vs. 92 min, P<0.0001) and used significantly less diagnostic radiation (median dose area product 5114 µGy•m2 vs. 8755 µGy•m2, P<0.0001). CONCLUSION CBCT-guided bronchoscopy with or without a robotic-assisted bronchoscopy platform is a safe and effective method for sampling PPLs, although the integration of a robotic-assisted platform was associated with significantly shorter procedure times and significantly less radiation exposure.
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Affiliation(s)
- Brian D Shaller
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - Duy K Duong
- Inova Interventional Pulmonology and Complex Airways Disease Program, Division of Thoracic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Kai E Swenson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Dwayne Free
- Department of Respiratory Care Services, Stanford Health Care, Stanford, CA
| | - Harmeet Bedi
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
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Shahoud J, Weksler B, Ghosh S, Ganesh A, Fernando H. Robot-Assisted Bronchoscopy for Identification of Lung Nodules During Minimally Invasive Pulmonary Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:263-267. [PMID: 38725309 DOI: 10.1177/15569845241247549] [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] [Indexed: 09/10/2024]
Abstract
OBJECTIVE Small pulmonary nodules can be difficult to identify during minimally invasive surgical (MIS) resection. Previous investigators have reported using standard bronchoscopy with electromagnetic navigation to identify small pulmonary nodules. Robot-assisted bronchoscopy has been introduced into clinical practice and has shown utility for the biopsy of small lesions. We report our experience using robot-assisted bronchoscopy with dye marking to aid in minimally invasive pulmonary resection. METHODS Patients with peripheral pulmonary nodules underwent robot-assisted bronchoscopy before a planned minimally invasive resection. Indocyanine green or methylene blue was injected directly into the targeted lesion. Surgical resection was then immediately performed. Success was defined as dye visualization leading to sublobar resection of the target nodule without the need for lobectomy or thoracotomy. RESULTS Thirty patients with a single targeted nodule underwent robot-assisted bronchoscopy followed by MIS resection. The median lesion size was 9 mm (4 to 25 mm), and the median distance from the pleura was 5 mm (1 to 32 mm). The success rate was 83.3% (25 of 30). There were 3 cases in which the dye was not visualized, and in 2 cases there was free extravasation of dye. The targeted nodule was identified in these 5 patients without the need for thoracotomy or lobectomy. Pathology revealed non-small cell lung cancer (n = 13, 43.3%), metastatic disease (n = 11, 36.7%), and benign disease (n = 6, 20%). There were no complications related to the use of robot-assisted bronchoscopy. CONCLUSIONS Robot-assisted bronchoscopy with dye marking is safe and effective for guiding minimally invasive resection of small peripheral pulmonary nodules.
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Affiliation(s)
- James Shahoud
- Department of Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Benny Weksler
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic and Esophageal Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Sohini Ghosh
- Department of Pulmonology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Aarthi Ganesh
- Department of Pulmonology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Hiran Fernando
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic and Esophageal Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
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Zhang C, Xie F, Li R, Cui N, Herth FJF, Sun J. Robotic-assisted bronchoscopy for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Thorac Cancer 2024; 15:505-512. [PMID: 38286133 PMCID: PMC10912532 DOI: 10.1111/1759-7714.15229] [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: 11/16/2023] [Revised: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 01/31/2024] Open
Abstract
Robotic-assisted bronchoscopy (RAB) is a newly developed bronchoscopic technique for the diagnosis of peripheral pulmonary lesions (PPLs). The objective of this meta-analysis was to analyze the diagnostic yield and safety of RAB in patients with PPLs. Five databases (PubMed, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov) were searched from inception to April 2023. Two independent investigators screened retrieved articles, extracted data, and assessed the study quality. The pooled diagnostic yield and complication rate were estimated. Subgroup analysis was used to explore potential sources of heterogeneity. Publication bias was assessed using funnel plots and the Egger test. Sensitivity analysis was also conducted to assess the robustness of the synthesized results. A total of 725 lesions from 10 studies were included in this meta-analysis. No publication bias was found. Overall, RAB had a pooled diagnostic yield of 80.4% (95% CI: 75.7%-85.1%). Lesion size of >30 mm, presence of a bronchus sign, and a concentric radial endobronchial ultrasound view were associated with a statistically significantly higher diagnostic yield. Heterogeneity exploration showed that studies using cryoprobes reported better yields than those without cryoprobes (90.0%, 95% CI: 83.2%-94.7% vs. 79.0%, 95% CI: 75.8%-82.2%, p < 0.01). The pooled complication rate was 3.0% (95% CI: 1.6%-4.4%). In conclusion, RAB is an effective and safe technique for PPLs diagnosis. Further high-quality prospective studies still need to be conducted.
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Affiliation(s)
- Chunxi Zhang
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care MedicineShanghai Chest Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care MedicineShanghai Chest Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Runchang Li
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care MedicineShanghai Chest Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Ningxin Cui
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care MedicineShanghai Chest Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Felix J. F. Herth
- Department of Pneumology and Critical Care Medicine, ThoraxklinikUniversity of HeidelbergHeidelbergGermany
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Department of Respiratory and Critical Care MedicineShanghai Chest Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
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Saad F, Frysch R, Saalfeld S, Kellnberger S, Schulz J, Fahrig R, Bhadra K, Nürnberger A, Rose G. Deformable 3D/3D CT-to-digital-tomosynthesis image registration in image-guided bronchoscopy interventions. Comput Biol Med 2024; 171:108199. [PMID: 38394801 DOI: 10.1016/j.compbiomed.2024.108199] [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: 08/11/2023] [Revised: 01/30/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024]
Abstract
Traditional navigational bronchoscopy procedures rely on preprocedural computed tomography (CT) and intraoperative chest radiography and cone-beam CT (CBCT) to biopsy peripheral lung lesions. This navigational approach is challenging due to the projective nature of radiography, and the high radiation dose, long imaging time, and large footprints of CBCT. Digital tomosynthesis (DTS) is considered an attractive alternative combining the advantages of radiography and CBCT. Only the depth resolution cannot match a full CBCT image due to the limited angle acquisition. To address this issue, preoperative CT is a good auxiliary in guiding bronchoscopy interventions. Nevertheless, CT-to-body divergence caused by anatomic changes and respiratory motion, hinders the effective use of CT imaging. To mitigate CT-to-body divergence, we propose a novel deformable 3D/3D CT-to-DTS registration algorithm employing a multistage, multiresolution approach and using affine and elastic B-spline transformation models with bone and lung mask images. A multiresolution strategy with a Gaussian image pyramid and a multigrid strategy within the B-spline model are applied. The normalized correlation coefficient is included in the cost function for the affine model and a multimetric weighted cost function is used for the B-spline model, with weights determined heuristically. Tested on simulated and real patient bronchoscopy data, the algorithm yields promising results. Assessed qualitatively by visual inspection and quantitatively by computing the Dice coefficient (DC) and the average symmetric surface distance (ASSD), the algorithm achieves mean DC of 0.82±0.05 and 0.74±0.05, and mean ASSD of 0.65±0.29mm and 0.93±0.43mm for simulated and real data, respectively. This algorithm lays the groundwork for CT-aided intraoperative DTS imaging in image-guided bronchoscopy interventions with future studies focusing on automated metric weight setting.
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Affiliation(s)
- Fatima Saad
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany.
| | - Robert Frysch
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany
| | - Sylvia Saalfeld
- Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany; Department of Simulation and Graphics, Otto-von-Guericke University, Magdeburg, Germany
| | | | - Jessica Schulz
- Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany; Siemens Healthcare GmbH, Forchheim, Germany
| | | | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, USA
| | - Andreas Nürnberger
- Data and Knowledge Engineering Group, Faculty of Computer Science, Otto-von-Guericke University, Magdeburg, Germany
| | - Georg Rose
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany
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Miyake K, Shiroyama T, Satoh S, Adachi Y, Ohira K, Abe Y, Takata S, Masuhiro K, Naito Y, Hirata H, Nagatomo I, Takeda Y, Kumanogoh A. Balloon Dilatation for Bronchoscope Delivery in a Swine Model: A Novel Technique for Ultra-Peripheral Lung Field Access and Accurate Biopsy. Respiration 2024; 103:205-213. [PMID: 38316121 DOI: 10.1159/000536666] [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: 11/03/2023] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION In transbronchial biopsy of peripheral pulmonary lesions, the bronchoscope can reach only a limited depth due to the progressive narrowing of bronchi, which may reduce the diagnostic rate. This study examined the balloon dilatation for bronchoscope delivery (BDBD) technique, employing a novel balloon device to enhance bronchoscopy into the peripheral lung areas. METHODS Anaesthetised swine served as our primary model. Using computed tomography (CT) scans, we positioned virtual targets characterised by a positive bronchus sign and a diameter of 20 mm beneath the pleura. The bronchoscope was navigated along the pathways determined from the CT images. We performed balloon dilatation when bronchial narrowing obstructed progress to assess whether balloon dilatation would enable the bronchoscope to enter further into the periphery. RESULTS We established 21 virtual targets on the CT scans. An average of 12.1 branches were identified along the pathways on the CT scans; however, bronchoscopy without BDBD only allowed access to an average of 6.7 branches. Based on 72 balloon dilatations with 3.0-mm or 4.0-mm ultra-thin bronchoscopes, there was an average increased access of 3.43 and 5.14 branches per route, respectively, with no significant BDBD complications. The bronchoscope was able to reach the planned location along all pathways, and the mean final bronchoscopic endpoints were at an average distance of 14.7 mm from the pleura. Post-procedure CT confirmed biopsy accuracy. CONCLUSION The BDBD technique can enhance access of a flexible bronchoscope into the peripheral lung fields, which could potentially allow more accurate transbronchial interventions for peripheral targets.
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Affiliation(s)
- Kotaro Miyake
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Takayuki Shiroyama
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Shingo Satoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yuichi Adachi
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Kika Ohira
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yuko Abe
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - So Takata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Kentaro Masuhiro
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yujiro Naito
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Izumi Nagatomo
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yoshito Takeda
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
- Department of Immunopathology, World Premier Institute Immunology Frontier Research Centre (WPI-IFReC), Osaka University, Osaka, Japan
- Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Osaka, Japan
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Bitter T, Seeba T, Schroeder-Richter J, Fröhlich M, Duaer W, Abidi W, Kindermann MP. [4D electromagnetic navigation bronchoscopy for the diagnosis of peripheral pulmonary nodules - An overview and preliminary clinical results]. Pneumologie 2024; 78:93-99. [PMID: 38081219 DOI: 10.1055/a-2193-0966] [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: 02/18/2024]
Abstract
BACKGROUND The diagnostic of peripheral pulmonary nodules (PPN) is a particular challenge in interventional bronchology, which is why navigation systems such as electromagnetic navigation (ENB) are increasingly being used. The 4D-ENB represents the most current development of the ENB. It utilizes inspiratory and expiratory CT scans for mapping and thus helps compensate for respiratory movements-induced CT-to-body divergence. The aim of this work was to present the first clinical data and experiences using the 4D-ENB method for diagnosis of PPNs. METHODS We retrospectively describe the results of the first nine consecutive patient cases diagnosed at Klinikum Braunschweig using 4D-ENB in a unimodal diagnostic procedure. RESULTS Of the first 9 PPNs examined by 4D-ENB, navigation and puncture of the lesion was successful in 8 patients (89%). Diagnostic biopsy was could be carried out in six out of nine patients (67%). There were no significant procedure-related complications. CONCLUSION Our preliminary data suggest that 4D-ENB is a promising new alternative for the diagnosis of PPNs. To further improve diagnostic yield, 4D-END, which lacks real-time visualization, should be embedded in a multimodal diagnostic procedure with rEBUS and/or fluoroscopy.
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Affiliation(s)
- Thomas Bitter
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Tielko Seeba
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Jörn Schroeder-Richter
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Michael Fröhlich
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Wissam Duaer
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Wael Abidi
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
| | - Markus Peter Kindermann
- Pneumology and respiratory medicine, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Deutschland
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Gamal A, Moschovas MC, Jaber AR, Saikali S, Perera R, Headley C, Patel E, Rogers T, Roche MW, Leveillee RJ, Albala D, Patel V. Clinical applications of robotic surgery platforms: a comprehensive review. J Robot Surg 2024; 18:29. [PMID: 38231279 DOI: 10.1007/s11701-023-01815-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/27/2023] [Indexed: 01/18/2024]
Abstract
Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time.
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Affiliation(s)
- Ahmed Gamal
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA.
| | - Marcio Covas Moschovas
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
- University of Central Florida (UCF), Orlando, FL, USA
| | - Abdel Rahman Jaber
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Shady Saikali
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Roshane Perera
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Chris Headley
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Ela Patel
- Stanford University, Palo Alto, CA, USA
| | - Travis Rogers
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
| | - Martin W Roche
- Department of Arthroplasty, Hospital for Special Surgery Florida, West Palm Beach, FL, USA
| | | | - David Albala
- Associated Medical Professionals, Urology, Syracuse, NY, USA
| | - Vipul Patel
- Adventhealth Global Robotics Institute, 380 Celebration Place, Orlando, FL, 34747, USA
- University of Central Florida (UCF), Orlando, FL, USA
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11
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Graham J, Basist M, Frye L, Agrawal A, Nasim F. Advances in navigating to the nodule and targeting. Curr Opin Pulm Med 2024; 30:9-16. [PMID: 37930633 DOI: 10.1097/mcp.0000000000001021] [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: 11/07/2023]
Abstract
PURPOSE OF REVIEW The multitude of available platforms and imaging modalities for navigational bronchoscopy, in combination with the various sampling tools that can be used intra-procedurally, is complex. This review seeks to describe the recent developments in peripheral bronchoscopy in regards to navigation, imaging, and sampling target lesions in the pulmonary parenchyma. RECENT FINDINGS Robotic assisted bronchoscopy has improved navigation to the peripheral airways for sampling of peripheral parenchymal lesions. These navigational platforms use innovative technology utilizing electromagnetic navigation and shape-sensing technology for guidance. The greatest improvement has been the stabilization of the robotic scope in the periphery to allow for accurate sampling. Despite improvements in these platforms, limitations of CT to body divergence continue to impact navigation to the lesion and therefore diagnostic yield of the procedure. Advanced intraprocedural imaging with cone beam CT or augmented fluoroscopy has been a recent focus to improve this area. Further, the adoption of newer sampling tools, such as cryobiopsy, offers the possibility of increased diagnostic yield. SUMMARY The developments in advanced bronchoscopy will impact the role of biopsy in the diagnosis of peripheral pulmonary parenchymal lesions.
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Affiliation(s)
- Jeffrey Graham
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Madeleine Basist
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Laura Frye
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Faria Nasim
- Interventional Pulmonology, Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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12
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Chang ATC, Ng CSH, Nezami N. Treatment strategies for malignant pulmonary nodule: beyond lobectomy. Point-counterpoint. Curr Opin Pulm Med 2024; 30:35-47. [PMID: 37916619 DOI: 10.1097/mcp.0000000000001027] [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: 11/03/2023]
Abstract
PURPOSE OF REVIEW Technological advancement in low-dose computed tomography resulted in an increased incidental discovery of early-stage lung cancer and multifocal ground glass opacity. The demand for parenchyma-preserving treatment strategies is greater now than ever. Pulmonary ablative therapy is a groundbreaking technique to offer local ablative treatment in a lung-sparing manner. It has become a promising technique in lung cancer management with its diverse applicability. In this article, we will review the current development of ablative therapy in lung and look into the future of this innovative technique. RECENT FINDINGS Current literature suggests that ablative therapy offers comparable local disease control to other local therapies and stereotactic body radiation therapy (SBRT), with a low risk of complications. In particular, bronchoscopic microwave ablation (BMWA) has considerably fewer pleural-based complications due to the avoidance of pleural puncture. BMWA can be considered in the multidisciplinary treatment pathway as it allows re-ablation and allows SBRT after BMWA. SUMMARY With the benefits which ablative therapy offers and its ability to incorporate into the multidisciplinary management pathway, we foresee ablative therapy, especially BMWA gaining significance in lung cancer treatment. Future directions on developing novel automated navigation platforms and the latest form of ablative energy would further enhance clinical outcomes for our patients.
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Affiliation(s)
- Aliss Tsz Ching Chang
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Calvin S H Ng
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore
- The Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, University of Maryland, Colleague Park, , Maryland, USA
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13
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Patel PP, Duong DK, Mahajan AK, Imai TA. Single Setting Robotic Lung Nodule Diagnosis and Resection. Thorac Surg Clin 2023; 33:233-244. [PMID: 37414479 DOI: 10.1016/j.thorsurg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Lung cancer remains the leading cause of cancer-related deaths. Early tissue diagnosis followed by timely therapeutic procedures can have a significant impact on overall survival. While robotic-assisted lung resection is an established therapeutic procedure, robotic-assisted bronchoscopy is a more recent diagnostic procedure that improves reach, stability, and precision in the field of bronchoscopic lung nodule biopsy. The ability to combine lung cancer diagnostics with therapeutic surgical resection into a single-setting anesthesia procedure has the potential to decrease costs, improve patient experiences, and most importantly, reduce delays in cancer care.
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Affiliation(s)
- Priya P Patel
- Interventional Pulmonology, Inova Health System, Schar Cancer Institute, 8081 Innovation Park Drive, Suite 3000, Fairfax, VA 22031, USA.
| | - Duy Kevin Duong
- Interventional Pulmonology, Inova Health System, Schar Cancer Institute, 8081 Innovation Park Drive, Suite 3000, Fairfax, VA 22031, USA
| | - Amit K Mahajan
- Interventional Pulmonology, Inova Health System, Schar Cancer Institute, 8081 Innovation Park Drive, Suite 3000, Fairfax, VA 22031, USA
| | - Taryne A Imai
- The Queen's University Medical Group, Queen's Health System, University of Hawaii, 1356 Lusitana Street, 6th floor, Honolulu, HI 96813, USA
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14
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Duke JD, Reisenauer J. Robotic bronchoscopy: potential in diagnosing and treating lung cancer. Expert Rev Respir Med 2023; 17:213-221. [PMID: 36939545 DOI: 10.1080/17476348.2023.2192929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Lung cancer remains the deadliest form of cancer in the world. Screening through low-dose CT scans has shown improved detection of pulmonary nodules; however, with the introduction of robotic bronchoscopy, accessing and biopsying peripheral pulmonary nodules from the airway has expanded. Improved diagnostic yield through enhanced navigation has made robotic bronchoscopy an ideal diagnostic technology for many proceduralists. Studies have demonstrated that robotic bronchoscopes can reach further with improved maneuverability into the distal airways compared to conventional bronchoscopes. AREAS COVERED This review paper highlights the literature on the technological advancements associated with robotic bronchoscopy and the future directions the field of interventional pulmonary may utilize this modality for in the treatment of lung cancer. Referenced articles were included at the discretion of the authors after a database search of the particular technology discussed. EXPERT OPINION As the localization of target lesions continues to improve, robotic platforms that provide reach, stability, and accuracy paves the way for future research in endoluminal treatment for lung cancer. Future studies with intratumoral injection of chemotherapy and immunotherapy and ablation modalities are likely to come in the coming years.
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Affiliation(s)
- Jennifer D Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic Rochester, Rochester, MN, USA
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15
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Duan X, Xie D, Zhang R, Li X, Sun J, Qian C, Song X, Li C. A Novel Robotic Bronchoscope System for Navigation and Biopsy of Pulmonary Lesions. CYBORG AND BIONIC SYSTEMS 2023; 4:0013. [PMID: 36951809 PMCID: PMC10026825 DOI: 10.34133/cbsystems.0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/05/2023] [Indexed: 02/08/2023] Open
Abstract
Transbronchial biopsy sampling, as a minimally invasive method with relatively low risk, has been proved to be a promising treatment in the field of respiratory surgery. Although several robotic bronchoscopes have been developed, it remains a great challenge to balance size and flexibility, while integrating multisensors to realize navigation during complex airway networks. This paper proposes a novel robotic bronchoscope system composed by end effector with relatively small size, relevant actuation unit, and navigation system with path planning and surgical guidance capability. The main part of the end effector is machined by bidirectional groove on a nickel-titanium tube, which can realize bending, rotation, and translation 3 degrees of freedom. A prototype of the proposed robotic bronchoscope system is designed and fabricated, and its performance is tested through several experiments to verify the stiffness, flexibility, and navigation performance. The results show that the proposed system is with good environment adaptiveness, and it can become a promising biopsy method through natural cavity of the human body.
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Affiliation(s)
- Xingguang Duan
- School of Medical Technology,
Beijing Institute of Technology, Beijing 100081, China
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
| | - Dongsheng Xie
- School of Medical Technology,
Beijing Institute of Technology, Beijing 100081, China
| | - Runtian Zhang
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
| | - Xiaotian Li
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
| | - Jiali Sun
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
| | - Chao Qian
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
| | - Xinya Song
- School of Medical Technology,
Beijing Institute of Technology, Beijing 100081, China
| | - Changsheng Li
- School of Mechatronical Engineering,
Beijing Institute of Technology, Beijing 100081, China
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16
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Advanced Imaging for Robotic Bronchoscopy: A Review. Diagnostics (Basel) 2023; 13:diagnostics13050990. [PMID: 36900134 PMCID: PMC10001114 DOI: 10.3390/diagnostics13050990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Recent advances in navigational platforms have led bronchoscopists to make major strides in diagnostic interventions for pulmonary parenchymal lesions. Over the last decade, multiple platforms including electromagnetic navigation and robotic bronchoscopy have allowed bronchoscopists to safely navigate farther into the lung parenchyma with increased stability and accuracy. Limitations persist, even with these newer technologies, in achieving a similar or higher diagnostic yield when compared to the transthoracic computed tomography (CT) guided needle approach. One of the major limitations to this effect is due to CT-to-body divergence. Real-time feedback that better defines the tool-lesion relationship is vital and can be obtained with additional imaging using radial endobronchial ultrasound, C-arm based tomosynthesis, cone-beam CT (fixed or mobile), and O-arm CT. Herein, we describe the role of this adjunct imaging with robotic bronchoscopy for diagnostic purposes, describe potential strategies to counteract the CT-to-body divergence phenomenon, and address the potential role of advanced imaging for lung tumor ablation.
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17
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Xie F, Wagh A, Wu R, Hogarth DK, Sun J. Robotic-assisted bronchoscopy in the diagnosis of peripheral pulmonary lesions. CHINESE MEDICAL JOURNAL PULMONARY AND CRITICAL CARE MEDICINE 2023; 1:30-35. [PMID: 39170876 PMCID: PMC11332856 DOI: 10.1016/j.pccm.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/07/2022] [Accepted: 01/09/2023] [Indexed: 08/23/2024]
Abstract
More peripheral pulmonary lesions (PPLs) are detected by low-dose helical computed tomography (CT) either incidentally or via dedicated lung cancer screening programs. Thus, using methods for safe and accurate diagnosis of these lesions has become increasingly important. Transthoracic needle aspiration (TTNA) and transbronchial lung biopsy (TBLB) are routinely performed during the diagnostic workup for PPLs. However, TTNA often carries the risk of pneumothorax, uncontrollable airway hemorrhage, and does not allow mediastinal staging in one procedure. In contrast, traditional TBLB often has a poorer diagnostic yield despite fewer complications. With the ongoing development of technology applied to bronchoscopy, guided bronchoscopy has become widely used and the diagnostic yield of TBLB has improved. Additionally, guided bronchoscopy continues to demonstrate a better safety profile than TTNA. In recent years, robotic-assisted bronchoscopy (RAB) has been introduced and implemented in the diagnosis of PPLs. At present, RAB has two platforms that are commercially available: Monarch™ and Ion™; several other platforms are under development. Both systems differ in characteristics, advantages, and limitations and offer features not seen in previous guided bronchoscopy. Several studies, including cadaveric model studies and clinical trials, have been conducted to examine the feasibility and performance of RAB using these two systems; large multicenter studies are underway. In this review, published experimental results, focusing on diagnostic yield and complications of RAB, are analyzed and the potential clinical application of RAB is discussed, which will enable the operators to have a clear overview of RAB.
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Affiliation(s)
- Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
| | - Ajay Wagh
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Ruolan Wu
- Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - D. Kyle Hogarth
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
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18
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Chan JWY, Siu ICH, Chang ATC, Li MSC, Lau RWH, Mok TSK, Ng CSH. Transbronchial Techniques for Lung Cancer Treatment: Where Are We Now? Cancers (Basel) 2023; 15:1068. [PMID: 36831411 PMCID: PMC9954491 DOI: 10.3390/cancers15041068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/29/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
The demand for parenchyma-sparing local therapies for lung cancer is rising owing to an increasing incidence of multifocal lung cancers and patients who are unfit for surgery. With the latest evidence of the efficacy of lung cancer screening, more premalignant or early-stage lung cancers are being discovered and the paradigm has shifted from treatment to prevention. Transbronchial therapy is an important armamentarium in the local treatment of lung cancers, with microwave ablation being the most promising based on early to midterm results. Adjuncts to improve transbronchial ablation efficiency and accuracy include mobile C-arm platforms, software to correct for the CT-to-body divergence, metal-containing nanoparticles, and robotic bronchoscopy. Other forms of energy including steam vapor therapy and pulse electric field are under intensive investigation.
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Affiliation(s)
- Joyce W. Y. Chan
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ivan C. H. Siu
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Aliss T. C. Chang
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Molly S. C. Li
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rainbow W. H. Lau
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tony S. K. Mok
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Calvin S. H. Ng
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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19
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Freyaldenhoven ST, Tsukada H. Robotics in the diagnosis and staging of lung cancer. J Surg Oncol 2023; 127:258-261. [PMID: 36630090 DOI: 10.1002/jso.27189] [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: 11/18/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023]
Abstract
The diagnosis of peripheral small lung lesions by electromagnetic navigational bronchoscopy is still inferior to computed tomography (CT) guided percutaneous transthoracic needle lung biopsy. Robotic bronchoscopy is a new technology that may be a potential breakthrough in the diagnosis of small lung lesions. Real-time tools such as electromagnetic navigation, radial-endobronchial ultrasound, and cone beam CT may further improve the diagnostic yield rate may further improve the diagnostic yield rate. In this article, we reviewed early experience of robotic bronchoscopy for diagnosis and staging of lung cancer.
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Affiliation(s)
- Samuel T Freyaldenhoven
- Department of Surgery, Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hisashi Tsukada
- Department of Surgery, Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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20
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Robotic Bronchoscopy: Review of Three Systems. Life (Basel) 2023; 13:life13020354. [PMID: 36836710 PMCID: PMC9962823 DOI: 10.3390/life13020354] [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: 01/04/2023] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/31/2023] Open
Abstract
Robotic bronchoscopy (RB) has been shown to improve access to smaller and more peripheral lung lesions, while simultaneously staging the mediastinum. Pre-clinical studies demonstrated extremely high diagnostic yields, but real-world RB yields have yet to fully matched up in prospective studies. Despite this, RB technology has rapidly evolved and has great potential for lung-cancer diagnosis and even treatment. In this article, we review the historical and present challenges with RB in order to compare three RB systems.
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21
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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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22
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De Leon H, Royalty K, Mingione L, Jaekel D, Periyasamy S, Wilson D, Laeseke P, Stoffregen WC, Muench T, Matonick JP, Kaluza GL, Cipolla G. Device safety assessment of bronchoscopic microwave ablation of normal swine peripheral lung using robotic-assisted bronchoscopy. Int J Hyperthermia 2023; 40:2187743. [PMID: 36944369 DOI: 10.1080/02656736.2023.2187743] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION The aim of this study was to assess the safety of bronchoscopic microwave ablation (MWA) of peripheral lung parenchyma using the NEUWAVE™ FLEX Microwave Ablation System, and robotic-assisted bronchoscopy (RAB) using the MONARCH™ Platform in a swine model. METHODS Computed tomography (CT)-guided RAB MWA was performed in the peripheral lung parenchyma of 17 Yorkshire swine (40-50 kg) and procedural adverse events (AEs) documented. The acute group (day 0, n = 5) received 4 MWAs at 100 W for 1, 3, 5, and 10 min in 4 different lung lobes. Subacute and chronic groups (days 3 and 30, n = 6 each) received one MWA (100 W, 10 min) per animal. RESULTS The study was completed without major procedural complications. No postprocedural AEs including death, pneumothorax, bronchopleural fistula, hemothorax, or pleural effusions were observed. No gross or histological findings suggestive of thromboembolism were found in any organ. One 3-Day and one 30-Day swine exhibited coughing that required no medication (minor AEs), and one 30-Day animal required antibiotic medication (major AE) for a suspected lower respiratory tract infection that subsided after two weeks. CT-based volumetric estimates of ablation zones in the acute group increased in an ablation time-dependent (1-10 min) manner, whereas macroscopy-based estimates showed an increasing trend in ablation zone size. CONCLUSION The NEUWAVE FLEX and MONARCH devices were safely used to perform single or multiple RAB MWAs. The preclinical procedural safety profile of RAB MWA supports clinical research of both devices to investigate efficacy in select patients with oligometastatic disease or primary NSCLC.
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Affiliation(s)
| | | | | | | | - Sarvesh Periyasamy
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - David Wilson
- Schneck Pulmonology, Schneck Medical Center, Seymour, IN, USA
| | - Paul Laeseke
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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The Feasibility of Using the "Artery Sign" for Pre-Procedural Planning in Navigational Bronchoscopy for Parenchymal Pulmonary Lesion Sampling. Diagnostics (Basel) 2022; 12:diagnostics12123059. [PMID: 36553068 PMCID: PMC9777140 DOI: 10.3390/diagnostics12123059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) and robotic-assisted bronchoscopy (RAB) systems are used for pulmonary lesion sampling, and utilize a pre-procedural CT scan where an airway, or "bronchus sign", is used to map a pathway to the target lesion. However, up to 40% of pre-procedural CT's lack a "bronchus sign" partially due to surrounding emphysema or limitation in CT resolution. Recognizing that the branches of the pulmonary artery, lymphatics, and airways are often present together as the bronchovascular bundle, we postulate that a branch of the pulmonary artery ("artery sign") could be used for pathway mapping during navigation bronchoscopy when a "bronchus sign" is absent. Herein we describe the navigation success and safety of using the "artery sign" to create a pathway for pulmonary lesion sampling. METHODS We reviewed data on consecutive cases in which the "artery sign" was used for pre-procedural planning for conventional ENB (superDimension™, Medtronic) and RAB (Monarch™, Johnson & Johnson). Patients who underwent these procedures from July 2020 until July 2021 at the University of Minnesota Medical Center and from June 2018 until December 2019 at the University of Chicago Medical Center were included in this analysis (IRB #19-0011 for the University of Chicago and IRB #00013135 for the University of Minnesota). The primary outcome was navigation success, defined as successfully maneuvering the bronchoscope to the target lesion based on feedback from the navigation system. Secondary outcomes included navigation success based on radial EBUS imaging, pneumothorax, and bleeding rates. RESULTS A total of 30 patients were enrolled in this analysis. The median diameter of the lesions was 17 mm. The median distance of the lesion from the pleura was 5 mm. Eleven lesions were solid, 15 were pure ground glass, and 4 were mixed. All cases were planned successfully using the "artery sign" on either the superDimension™ ENB (n = 15) or the Monarch™ RAB (n = 15). Navigation to the target was successful for 29 lesions (96.7%) based on feedback from the navigation system (virtual target). Radial EBUS image was acquired in 27 cases (90%) [eccentric view in 13 (43.33%) and concentric view in 14 patients (46.66%)], while in 3 cases (10%) no r-EBUS view was obtained. Pneumothorax occurred in one case (3%). Significant airway bleeding was reported in one case (3%). CONCLUSIONS We describe the concept of using the "artery sign" as an alternative for planning EMN and RAB procedures when "bronchus sign" is absent. The navigation success based on virtual target or r-EBUS imaging is high and safety of sampling of such lesions compares favorably with prior reports. Prospective studies are needed to assess the impact of the "artery sign" on diagnostic yield.
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Transbronchial real-time lung tumor localization with folate receptor-targeted near-infrared molecular imaging: A proof of concept study in animal models. J Thorac Cardiovasc Surg 2022; 165:e240-e251. [PMID: 36882986 DOI: 10.1016/j.jtcvs.2022.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The diagnostic yield of bronchoscopy is not satisfactory, even with recent navigation technologies, especially for tumors located outside of the bronchial lumen. Our objective was to perform a preclinical assessment of folate receptor-targeted near-infrared imaging-guided bronchoscopy to detect peribronchial tumors. METHODS Pafolacianine, a folate receptor-targeted molecular imaging agent, was used as a near-infrared fluorescent imaging agent. An ultra-thin composite optical fiberscope was used for laser irradiation and fluorescence imaging. Subcutaneous xenografts of KB cells in mice were used as folate receptor-positive tumors. Tumor-to-background ratio was calculated by the fluorescence intensity value of muscle tissues acquired by the ultra-thin composite optical fiberscope system and validated using a separate spectral imaging system. Ex vivo swine lungs into which pafolacianine-laden KB tumors were transplanted at various sites were used as a peribronchial tumor model. RESULTS With the in vivo murine model, tumor-to-background ratio observed by ultra-thin composite optical fiberscope peaked at 24 hours after pafolacianine injection (tumor-to-background ratio: 2.56 at 0.05 mg/kg, 2.03 at 0.025 mg/kg). The fluorescence intensity ratios between KB tumors and normal mouse lung parenchyma postmortem were 6.09 at 0.05 mg/kg and 5.08 at 0.025 mg/kg. In the peribronchial tumor model, the ultra-thin composite optical fiberscope system could successfully detect fluorescence from pafolacianine-laden folate receptor-positive tumors with 0.05 mg/kg at the carina and those with 0.025 mg/kg and 0.05 mg/kg in the peripheral airway. CONCLUSIONS Transbronchial detection of pafolacianine-laden folate receptor-positive tumors by near-infrared imaging was feasible in ex vivo swine lungs. Further in vivo preclinical assessment is needed to confirm the feasibility of this technology.
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Manley CJ, Pritchett MA. Nodules, Navigation, Robotic Bronchoscopy, and Real-Time Imaging. Semin Respir Crit Care Med 2022; 43:473-479. [PMID: 36104024 DOI: 10.1055/s-0042-1747930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The process of detection, diagnosis, and management of lung nodules is complex due to the heterogeneity of lung pathology and a relatively low malignancy rate. Technological advances in bronchoscopy have led to less-invasive diagnostic procedures and advances in imaging technology have helped to improve nodule localization and biopsy confirmation. Future research is required to determine which modality or combination of complimentary modalities is best suited for safe, accurate, and cost-effective management of lung nodules.
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Affiliation(s)
- Christopher J Manley
- Division of Pulmonary and Critical Care, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania
| | - Michael A Pritchett
- Division of Pulmonary and Critical Care Medicine, Chest Center of the Carolinas at FirstHealth, FirstHealth of the Carolinas and Pinehurst Medical Clinic, Pinehurst, North Carolina
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Dupont PE, Simaan N, Choset H, Rucker C. Continuum Robots for Medical Interventions. PROCEEDINGS OF THE IEEE. INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS 2022; 110:847-870. [PMID: 35756186 PMCID: PMC9231641 DOI: 10.1109/jproc.2022.3141338] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Continuum robots are not constructed with discrete joints but, instead, change shape and position their tip by flexing along their entire length. Their narrow curvilinear shape makes them well suited to passing through body lumens, natural orifices, or small surgical incisions to perform minimally invasive procedures. Modeling and controlling these robots are, however, substantially more complex than traditional robots comprised of rigid links connected by discrete joints. Furthermore, there are many approaches to achieving robot flexure. Each presents its own design and modeling challenges, and to date, each has been pursued largely independently of the others. This article attempts to provide a unified summary of the state of the art of continuum robot architectures with respect to design for specific clinical applications. It also describes a unifying framework for modeling and controlling these systems while additionally explaining the elements unique to each architecture. The major research accomplishments are described for each topic and directions for the future progress needed to achieve widespread clinical use are identified.
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Affiliation(s)
- Pierre E Dupont
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Nabil Simaan
- Department of Mechanical Engineering, the Department of Computer Science, and the Department of Otolaryngology, Vanderbilt University, Nashville, TN 37235 USA
| | - Howie Choset
- Mechanical Engineering Department, the Biomedical Engineering Department, and the Robotics Institute, Carnegie Mellon, Pittsburgh, PA 15213 USA
| | - Caleb Rucker
- Department of Mechanical, Aerospace, and Biomedical Engineering, The University of Tennessee, Knoxville, TN 37996 USA
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Chan JWY, Chang ATC, Yu PSY, Lau RWH, Ng CSH. Robotic Assisted-Bronchoscopy With Cone-Beam CT ICG Dye Marking for Lung Nodule Localization: Experience Beyond USA. Front Surg 2022; 9:943531. [PMID: 35836599 PMCID: PMC9274119 DOI: 10.3389/fsurg.2022.943531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
Electromagnetic navigation bronchoscopy (ENB)-guided indocyanine green (ICG) fluorescence dye marking of subsolid, small and deep lung lesions facilitates subsequent minimally invasive lung resection surgeries. The novel robotic-assisted bronchoscopy (RAB) platform can improve the accuracy and yield of ENB biopsy, and the use of RAB has been extended to ICG dye marking. However, performing this procedure in the hybrid operating room guided by cone-beam CT (CBCT) with immediate proceed to lung surgery has not been well reported. We studied the safety, feasibility and clinical outcomes of 5 consecutive cases performed between December 2021 and March 2022. Navigation success was 100% while localization success using ICG was 80%. The benefits and pitfalls of robotic bronchoscopy procedures, and challenges of combining with hybrid operating room CBCT were discussed in detail. In conclusion, robotic-assisted bronchoscopy is a promising and useful tool for ICG fluorescence dye-marking, providing accurate navigation, superior maneuverability and improved ergonomics compared to conventional bronchoscopy-guided ENB procedures. Learning curve is reasonable, but meticulous system set up to incorporate the robotic system into existing CBCT platform may be required to ensure a smooth procedure.
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Shape-Sensing Robotic-Assisted Bronchoscopy in the Diagnosis of Pulmonary Parenchymal Lesions. Chest 2022; 161:572-582. [PMID: 34384789 PMCID: PMC8941601 DOI: 10.1016/j.chest.2021.07.2169] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/05/2021] [Accepted: 07/29/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The landscape of guided bronchoscopy for the sampling of pulmonary parenchymal lesions is evolving rapidly. Shape-sensing robotic-assisted bronchoscopy (ssRAB) recently was introduced as means to allow successful sampling of traditionally challenging lesions. RESEARCH QUESTION What are the feasibility, diagnostic yield, determinants of diagnostic sampling, and safety of ssRAB in patients with pulmonary lesions? STUDY DESIGN AND METHODS Data from 131 consecutive ssRAB procedures performed at a US-based cancer center between October 2019 and July 2020 were captured prospectively and analyzed retrospectively. Definitions of diagnostic procedures were based on prior standards. Associations of procedure- and lesion-related factors with diagnostic yield were examined by univariate and multivariate generalized linear mixed models. RESULTS A total of 159 pulmonary lesions were targeted during 131 ssRAB procedures. The median lesion size was 1.8 cm, 59.1% of lesions were in the upper lobe, and 66.7% of lesions were beyond a sixth-generation airway. The navigational success rate was 98.7%. The overall diagnostic yield was 81.7%. Lesion size of ≥ 1.8 cm and central location were associated significantly with a diagnostic procedure in the univariate analysis. In the multivariate model, lesions of ≥ 1.8 cm were more likely to be diagnostic compared with lesions < 1.8 cm, after adjusting for lung centrality (OR, 12.22; 95% CI, 1.66-90.10). The sensitivity and negative predictive value of ssRAB for primary thoracic malignancies were 79.8% and 72.4%, respectively. The overall complication rate was 3.0%, and the pneumothorax rate was 1.5%. INTERPRETATION This study was the first to provide comprehensive evidence regarding the usefulness and diagnostic yield of ssRAB in the sampling of pulmonary parenchymal lesions. ssRAB may represent a significant advancement in the ability to access and sample successfully traditionally challenging pulmonary lesions via the bronchoscopic approach, while maintaining a superb safety profile. Lesion size seems to remain the major predictor of a diagnostic procedure.
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Agrawal A, Ho E, Chaddha U, Demirkol B, Bhavani SV, Hogarth DK, Murgu S. Factors Associated with Diagnostic Accuracy of Robotic Bronchoscopy with 12-month Follow-up. Ann Thorac Surg 2022; 115:1361-1368. [PMID: 35051388 DOI: 10.1016/j.athoracsur.2021.12.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/09/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Robotic Bronchoscopy (RB) aims to increase the diagnostic yield of guided bronchoscopy by providing improved navigation, farther reach, and stability during lesion sampling. METHODS We reviewed data on consecutive cases in which robotic bronchoscopy was used to diagnose lung lesions from June 15th, 2018 to December 15th, 2019 at the University of Chicago Medical Center. RESULTS The median lesion size was 20.5 mm. All patients had at least 12 months of follow-up. The overall diagnostic accuracy was 77% (95/124). The diagnostic accuracy was 85%, 84% and 38% for concentric, eccentric and absent r-EBUS views, respectively (p < 0.001). A positive r-EBUS view and lesions size of 20-30 mm had higher odds of achieving a diagnosis on multivariate analysis. The 12-month diagnostic accuracy, sensitivity, specificity, positive and negative predictive value for malignancy was 77%, 69%, 100%, 100% and 58%, respectively. Pneumothorax was noted in 1.6% (2) cases with bleeding reported in 3.2% (4) cases. No post-procedure respiratory failure was noted. CONCLUSIONS The overall diagnostic accuracy using RB for pulmonary lesion sampling in our cohort with 12-month follow-up compared favorably to established guided bronchoscopy technologies. Lesion size ≥20 mm and confirmation by r-EBUS predicted higher accuracy independent of concentric or eccentric r-EBUS patterns.
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Affiliation(s)
- Abhinav Agrawal
- Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York.
| | - Elliot Ho
- Section of Pulmonary and Critical Care, The University of Chicago, Chicago, Illinois
| | - Udit Chaddha
- Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Baris Demirkol
- Department of Pulmonary Diseases, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - D Kyle Hogarth
- Section of Pulmonary and Critical Care, The University of Chicago, Chicago, Illinois
| | - Septimiu Murgu
- Section of Pulmonary and Critical Care, The University of Chicago, Chicago, Illinois
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Deep learning for anatomical interpretation of video bronchoscopy images. Sci Rep 2021; 11:23765. [PMID: 34887497 PMCID: PMC8660867 DOI: 10.1038/s41598-021-03219-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022] Open
Abstract
Anesthesiologists commonly use video bronchoscopy to facilitate intubation or confirm the location of the endotracheal tube; however, depth and orientation in the bronchial tree can often be confused because anesthesiologists cannot trace the airway from the oropharynx when it is performed using an endotracheal tube. Moreover, the decubitus position is often used in certain surgeries. Although it occurs rarely, the misinterpretation of tube location can cause accidental extubation or endobronchial intubation, which can lead to hyperinflation. Thus, video bronchoscopy with a decision supporting system using artificial intelligence would be useful in the anesthesiologic process. In this study, we aimed to develop an artificial intelligence model robust to rotation and covering using video bronchoscopy images. We collected video bronchoscopic images from an institutional database. Collected images were automatically labeled by an optical character recognition engine as the carina and left/right main bronchus. Except 180 images for the evaluation dataset, 80% were randomly allocated to the training dataset. The remaining images were assigned to the validation and test datasets in a 7:3 ratio. Random image rotation and circular cropping were applied. Ten kinds of pretrained models with < 25 million parameters were trained on the training and validation datasets. The model showing the best prediction accuracy for the test dataset was selected as the final model. Six human experts reviewed the evaluation dataset for the inference of anatomical locations to compare its performance with that of the final model. In the experiments, 8688 images were prepared and assigned to the evaluation (180), training (6806), validation (1191), and test (511) datasets. The EfficientNetB1 model showed the highest accuracy (0.86) and was selected as the final model. For the evaluation dataset, the final model showed better performance (accuracy, 0.84) than almost all human experts (0.38, 0.44, 0.51, 0.68, and 0.63), and only the most-experienced pulmonologist showed performance comparable (0.82) with that of the final model. The performance of human experts was generally proportional to their experiences. The performance difference between anesthesiologists and pulmonologists was marked in discrimination of the right main bronchus. Using bronchoscopic images, our model could distinguish anatomical locations among the carina and both main bronchi under random rotation and covering. The performance was comparable with that of the most-experienced human expert. This model can be a basis for designing a clinical decision support system with video bronchoscopy.
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A Review of Robotic-Assisted Bronchoscopy Platforms in the Sampling of Peripheral Pulmonary Lesions. J Clin Med 2021; 10:jcm10235678. [PMID: 34884380 PMCID: PMC8658555 DOI: 10.3390/jcm10235678] [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: 11/09/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022] Open
Abstract
Robotic-assisted bronchoscopy is one of the newest additions to clinicians’ armamentarium for the biopsy of peripheral pulmonary lesions in light of the suboptimal yields and sensitivities of conventional bronchoscopic platforms. In this article, we review the existing literature pertaining to the feasibility as well as sensitivity of available robotic-assisted bronchoscopic platforms.
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Shen YC, Chen CH, Tu CY. Advances in Diagnostic Bronchoscopy. Diagnostics (Basel) 2021; 11:diagnostics11111984. [PMID: 34829331 PMCID: PMC8620115 DOI: 10.3390/diagnostics11111984] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022] Open
Abstract
The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.
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Affiliation(s)
- Yi-Cheng Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung 40447, Taiwan
| | - Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 40447, Taiwan
- Correspondence: (C.-H.C.); (C.-Y.T.); Tel.: +886-4-22052121 (ext. 2623) (C.-H.C.); +886-4-22052121 (ext. 3485) (C.-Y.T.); Fax: +886-4-22038883 (C.-H.C. & C.-Y.T.)
| | - Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan;
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 40447, Taiwan
- Correspondence: (C.-H.C.); (C.-Y.T.); Tel.: +886-4-22052121 (ext. 2623) (C.-H.C.); +886-4-22052121 (ext. 3485) (C.-Y.T.); Fax: +886-4-22038883 (C.-H.C. & C.-Y.T.)
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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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Robotic Bronchoscopy for Peripheral Pulmonary Lesion Biopsy: Evidence-Based Review of the Two Platforms. Diagnostics (Basel) 2021; 11:diagnostics11081479. [PMID: 34441413 PMCID: PMC8391906 DOI: 10.3390/diagnostics11081479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/20/2022] Open
Abstract
Despite many advancements in recent years for the sampling of peripheral pulmonary lesions, the diagnostic yield remains low. Initial excitement about the current electromagnetic navigation platforms has subsided as the real-world data shows a significantly lower diagnostic sensitivity of ~70%. “CT-to-body divergence” has been identified as a major limitation of this modality. In-tandem use of the ultrathin bronchoscope and radial endobronchial ultrasound probe has yielded only comparable results, attributable to the limited peripheral reach, device maneuverability, stability, and distractors like atelectasis. As such, experts have identified three key steps in peripheral nodule sampling—navigation (to the lesion), confirmation (of the correct location), and acquisition (tissue sampling by tools). Robotic bronchoscopy (RB) is a novel innovation that aspires to improve upon these aspects and consequently, achieve a better diagnostic yield. Through this publication, we aim to review the technical aspects, safety, feasibility, and early efficacy data for this new diagnostic modality.
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Robotic bronchoscopy for peripheral pulmonary lesions: a convergence of technologies. Curr Opin Pulm Med 2021; 27:229-239. [PMID: 33973554 DOI: 10.1097/mcp.0000000000000782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Robotic bronchoscopy is the newest advanced diagnostic bronchoscopy technology for biopsying peripheral pulmonary lesions; sensitivity for malignancy is currently suboptimal using modalities, such as radial endobronchial ultrasound or electromagnetic navigational bronchoscopy. We review the pitfalls of prior methods and the technological advancements with robotic bronchoscopy. RECENT FINDINGS The contributors to reduced diagnostic sensitivity with current approaches include limitations in: navigation to the target, confirmation once the target is reached, and tissue acquisition. CT to body divergence with virtual reality methods, such as with electromagnetic navigation, potential false-positive confirmation with radial endobronchial ultrasound because of intraprocedural induced atelectasis, and lack of bronchoscopic and instrument maneuverability are all limitations to improving sensitivity. Robotic bronchoscopy enhances navigation through target pathway selection, allows for further reach in the distal airways, and improves tissue acquisition with more flexible and maneuverable biopsy instruments but lacks a high-fidelity target confirmation system. SUMMARY Robotic bronchoscopy shows promise in biopsying peripheral lesions. Current published studies focus on diagnostic yield with robotic bronchoscopy. Future studies with long-term follow-up will be needed to assess diagnostic sensitivity for lung cancer and if robotic bronchoscopy is superior to other advanced diagnostic bronchoscopic techniques for peripheral pulmonary lesions.
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Masaki F, King F, Kato T, Tsukada H, Colson Y, Hata N. Technical validation of multi-section robotic bronchoscope with first person view control for transbronchial biopsies of peripheral lung. IEEE Trans Biomed Eng 2021; 68:3534-3542. [PMID: 33945467 DOI: 10.1109/tbme.2021.3077356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study aims to validate the advantage of the new engineering method to maneuver multi-section robotic bronchoscope with first person view control in transbronchial biopsy. Six physician operators were recruited and tasked to operate a manual and a robotic bronchoscope to the peripheral area placed in patient-derived lung phantoms. The metrics collected were the furthest generation count of the airway the bronchoscope reached, force incurred to the phantoms, and NASA-Task Load Index. The furthest generation count of the airway the physicians reached using the manual and the robotic bronchoscopes were 6.6 +/- 1.2th and 6.7 +/- 0.8th. Robotic bronchoscopes successfully reached the 5th generation count into the peripheral area of the airway, while the manual bronchoscope typically failed earlier in the 3rd generation. More force was incurred to the airway when the manual bronchoscope was used (0.24 +/- 0.20 [N]) than the robotic bronchoscope was applied (0.18 +/- 0.22 [N], p<0.05). The manual bronchoscope imposed more physical demand than the robotic bronchoscope by NASA-TLX score (55 +/- 24 vs 19 +/- 16, p<0.05). These results indicate that a robotic bronchoscope facilitates the advancement of the bronchoscope to the peripheral area with less physical demand to physician operators. The metrics collected in this study would expect to be used as a benchmark for the future development of robotic bronchoscopes.
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Fried I, Hoelscher J, Fu M, Emerson M, Ertop TE, Rox M, Granna J, Kuntz A, Akulian JA, Webster RJ, Alterovitz R. Design Considerations for a Steerable Needle Robot to Maximize Reachable Lung Volume. IEEE INTERNATIONAL CONFERENCE ON ROBOTICS AND AUTOMATION : ICRA : [PROCEEDINGS]. IEEE INTERNATIONAL CONFERENCE ON ROBOTICS AND AUTOMATION 2021; 2021:10.1109/icra48506.2021.9561342. [PMID: 34721939 PMCID: PMC8553157 DOI: 10.1109/icra48506.2021.9561342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Steerable needles that are able to follow curvilinear trajectories and steer around anatomical obstacles are a promising solution for many interventional procedures. In the lung, these needles can be deployed from the tip of a conventional bronchoscope to reach lung lesions for diagnosis. The reach of such a device depends on several design parameters including the bronchoscope diameter, the angle of the piercing device relative to the medial axis of the airway, and the needle's minimum radius of curvature while steering. Assessing the effect of these parameters on the overall system's clinical utility is important in informing future design choices and understanding the capabilities and limitations of the system. In this paper, we analyze the effect of various settings for these three robot parameters on the percentage of the lung that the robot can reach. We combine Monte Carlo random sampling of piercing configurations with a Rapidly-exploring Random Trees based steerable needle motion planner in simulated human lung environments to asymptotically accurately estimate the volume of sites in the lung reachable by the robot. We highlight the importance of each parameter on the overall system's reachable workspace in an effort to motivate future device innovation and highlight design trade-offs.
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Affiliation(s)
- Inbar Fried
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Janine Hoelscher
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Mengyu Fu
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Maxwell Emerson
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Tayfun Efe Ertop
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Margaret Rox
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Josephine Granna
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Alan Kuntz
- School of Computing and the Robotics Center, University of Utah, Salt Lake City, UT 84112, USA
| | - Jason A. Akulian
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27514, USA
| | - Robert J. Webster
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Ron Alterovitz
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Kalanjeri S, Abbasi A, Luthra M, Johnson JC. Invasive modalities for the diagnosis of peripheral lung nodules. Expert Rev Respir Med 2021; 15:781-790. [PMID: 33899654 DOI: 10.1080/17476348.2021.1913059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lung nodules are being increasingly discovered either incidentally or through lung cancer screening chest CT scans. Some of these will turn out to be malignant and therefore it is important to obtain an accurate and timely diagnosis of lung cancer when suspected. AREAS COVERED This review will cover various invasive diagnostic modalities available to sample lung nodules. Data from key studies, obtained from PubMed searches, will be reviewed. Emerging technologies such as cone-beam CT and robotic-assisted bronchoscopies will be discussed along with ddata available currently to support their use. EXPERT OPINION The best approach to diagnosing a lung nodule - whether found incidentally or because of lung cancer screening - is continuously evolving. While CT-guided lung nodule biopsy has a high diagnostic yield, the risk of pneumothorax is often a concern. Bronchoscopy has a better safety profile, but diagnostic ability falls short of CT-guided biopsy. Existing technologies such as electromagnetic navigation have not demonstrated a high diagnostic yield. Factors responsible for this relatively lower low diagnostic yield will be discussed in detail. Emerging technologies such as cone-beam CT scan and robotic bronchoscopy have addressed some of these issues and initial experience has demonstrated better diagnostic yield.
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Affiliation(s)
- Satish Kalanjeri
- Pulmonary and Critical Care Medicine, Harry S. Truman Memorial Veterans Hospital, University of Missouri School of Medicine, Columbia, MO, USA
| | - Anna Abbasi
- Anna Abbasi, Pulmonary and Critical Care Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Munish Luthra
- Munish Luthra, Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeremy C Johnson
- Pulmonary and Critical Care Medicine, Harry S. Truman Memorial Veterans Hospital, University of Missouri School of Medicine, Columbia, MO, USA
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Muñoz-Largacha JA, Batra H, Wei B. Navigational Bronchoscopy with Interventional Pulmonologists and Thoracic Surgeons. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:117-122. [PMID: 33754842 DOI: 10.1177/1556984521997421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Juan A Muñoz-Largacha
- 9968 Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, AL, USA
| | - Hitesh Batra
- 9967 Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Benjamin Wei
- 9968 Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, AL, USA
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Fernandes S, Williams G, Williams E, Ehrlich K, Stone J, Finlayson N, Bradley M, Thomson RR, Akram AR, Dhaliwal K. Solitary pulmonary nodule imaging approaches and the role of optical fibre-based technologies. Eur Respir J 2021; 57:2002537. [PMID: 33060152 PMCID: PMC8174723 DOI: 10.1183/13993003.02537-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 09/29/2020] [Indexed: 12/18/2022]
Abstract
Solitary pulmonary nodules (SPNs) are a clinical challenge, given there is no single clinical sign or radiological feature that definitively identifies a benign from a malignant SPN. The early detection of lung cancer has a huge impact on survival outcome. Consequently, there is great interest in the prompt diagnosis, and treatment of malignant SPNs. Current diagnostic pathways involve endobronchial/transthoracic tissue biopsies or radiological surveillance, which can be associated with suboptimal diagnostic yield, healthcare costs and patient anxiety. Cutting-edge technologies are needed to disrupt and improve, existing care pathways. Optical fibre-based techniques, which can be delivered via the working channel of a bronchoscope or via transthoracic needle, may deliver advanced diagnostic capabilities in patients with SPNs. Optical endomicroscopy, an autofluorescence-based imaging technique, demonstrates abnormal alveolar structure in SPNs in vivo Alternative optical fingerprinting approaches, such as time-resolved fluorescence spectroscopy and fluorescence-lifetime imaging microscopy, have shown promise in discriminating lung cancer from surrounding healthy tissue. Whilst fibre-based Raman spectroscopy has enabled real-time characterisation of SPNs in vivo Fibre-based technologies have the potential to enable in situ characterisation and real-time microscopic imaging of SPNs, which could aid immediate treatment decisions in patients with SPNs. This review discusses advances in current imaging modalities for evaluating SPNs, including computed tomography (CT) and positron emission tomography-CT. It explores the emergence of optical fibre-based technologies, and discusses their potential role in patients with SPNs and suspected lung cancer.
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Affiliation(s)
- Susan Fernandes
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Gareth Williams
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Elvira Williams
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Katjana Ehrlich
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - James Stone
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Centre for Photonics and Photonic Materials, Dept of Physics, The University of Bath, Bath, UK
| | - Neil Finlayson
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Institute for Integrated Micro and Nano Systems, School of Engineering, The University of Edinburgh, Edinburgh, UK
| | - Mark Bradley
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- EaStCHEM, School of Chemistry, The University of Edinburgh, Edinburgh, UK
| | - Robert R. Thomson
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Institute of Photonics and Quantum Sciences, School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK
| | - Ahsan R. Akram
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Kevin Dhaliwal
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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Navaei Lavasani S, Farnia P, Najafzadeh E, Saghatchi S, Samavati M, Abtahi H, Deevband M, Ahmadian A. Bronchoscope motion tracking using centerline-guided Gaussian mixture model in navigated bronchoscopy. Phys Med Biol 2021; 66:025001. [PMID: 33181494 DOI: 10.1088/1361-6560/abca07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Electromagnetic-based navigation bronchoscopy requires accurate and robust estimation of the bronchoscope position inside the bronchial tree. However, respiratory motion, coughing, patient movement, and airway deformation inflicted by bronchoscope significantly hinder the accuracy of intraoperative bronchoscopic localization. In this study, a real-time and automatic registration procedure was proposed to superimpose the current location of the bronchoscope to corresponding locations on a centerline extracted from bronchial computed tomography (CT) images. A centerline-guided Gaussian mixture model (CG-GMM) was introduced to register a bronchoscope's position concerning extracted centerlines. A GMM was fitted to bronchoscope positions where the orientation likelihood was chosen to assign the membership probabilities of the mixture model, which led to preserving the global and local structures. The problem was formulated and solved under the expectation maximization framework, where the feature correspondence and spatial transformation are estimated iteratively. Validation was performed on a dynamic phantom with four different respiratory motions and four human real bronchoscopy (RB) datasets. Results of the experiments conducted on the bronchial phantom showed that the average positional tracking error using the proposed approach was equal to 1.98 [Formula: see text] 0.98 mm that was reduced in comparison with independent electromagnetic tracking (EMT), iterative closest point (ICP), and coherent point drift (CPD) methods by 64%, 58%, and 53%, respectively. In the patient assessment part of the study, the average positional tracking error was 4.73 [Formula: see text] 4.76 mm and compared to ICP, and CPD methods showed 31.4% improvement of successfully tracked frames. Our approach introduces a novel method for real-time respiratory motion compensation that provides reliable guidance during bronchoscopic interventions and, thus could increase the diagnostic yield of transbronchial biopsy.
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Affiliation(s)
- Saeedeh Navaei Lavasani
- Biomedical Engineering and Medical Physics Department, School of Medicine, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran. Research Centre of Biomedical Technology and Robotics (RCBTR), Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Ho E, Agrawal A, Hogarth DK, Murgu S. What should we realistically expect from robotic bronchoscopy in the near future? J Thorac Dis 2021; 13:405-408. [PMID: 33570511 PMCID: PMC7867838 DOI: 10.21037/jtd-20-3323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Elliot Ho
- Section of Pulmonary and Critical Care/Interventional Pulmonology, The University of Chicago, Chicago, IL, USA
| | - Abhinav Agrawal
- Division of Pulmonary, Critical Care & Sleep Medicine/Interventional Pulmonology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Douglas Kyle Hogarth
- Section of Pulmonary and Critical Care/Interventional Pulmonology, The University of Chicago, Chicago, IL, USA
| | - Septimiu Murgu
- Section of Pulmonary and Critical Care/Interventional Pulmonology, The University of Chicago, Chicago, IL, USA
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43
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Ishiwata T, Seki T, Gregor A, Aragaki M, Motooka Y, Kinoshita T, Inage T, Bernards N, Ujiie H, Chen Z, Effat A, Chen J, Zheng G, Tatsumi K, Yasufuku K. A preclinical research platform to evaluate photosensitizers for transbronchial localization and phototherapy of lung cancer using an orthotopic mouse model. Transl Lung Cancer Res 2021; 10:243-251. [PMID: 33569308 PMCID: PMC7867757 DOI: 10.21037/tlcr-20-813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Establishing the efficacy of novel photosensitizers (PSs) for phototherapy of lung cancer requires in vivo study prior to clinical evaluation. However, previously described animal models are not ideal for assessing transbronchial approaches with such PSs. Methods An ultra-small parallel-type composite optical fiberscope (COF) with a 0.97 mm outer diameter tip. The integration of illumination and laser irradiation fibers inside the COF allows simultaneous white-light and fluorescence imaging, as well as real-time monitoring of tip position during laser phototherapy. An orthotopic lung cancer mouse model was created with three human lung cancer cell lines transbronchially inoculated into athymic nude mice. The COF was inserted transbronchially into a total of 15 mice for tumor observation. For in vivo fluorescence imaging, an organic nanoparticle, porphysome, was used as a PS. Laser excitation through the COF was performed at 50 mW using a 671 nm source. Results The overall success rate for creating orthotopic lung tumors was 71%. Transbronchial white light images were successfully captured by COF. Access to the left main bronchus was successful in 87% of mice (13/15), the right main bronchus to the cranial lobe bronchus level in 100% (15/15), and to the right basal trifurcation of the middle lobe, caudal lobe and accessory lobe in 93% (14/15). For transbronchial tumor localization of orthotopic lung cancer tumors, PS-laden tumor with the strong signal was clearly contrasted from the normal bronchial wall. Conclusions The ultra-small COF enabled reliable transbronchial access to orthotopic human lung cancer xenografts in vivo. This method could serve as a versatile preclinical research platform for PS evaluation in lung cancer, enabling transbronchial approaches in in vivo survival models inoculated with human lung cancer cells.
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Affiliation(s)
- Tsukasa Ishiwata
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takeshi Seki
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Mechanical Engineering Course, Department of System Design Engineering, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Alexander Gregor
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Masato Aragaki
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yamato Motooka
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Tomonari Kinoshita
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Terunaga Inage
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nicholas Bernards
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hideki Ujiie
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Zhenchian Chen
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Andrew Effat
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Juan Chen
- Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Ontario, Canada
| | - Gang Zheng
- Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Ontario, Canada.,TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network/University of Toronto, Toronto, Ontario, Canada.,TECHNA Institute for the Advancement of Technology for Health, University Health Network, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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44
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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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45
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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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Abstract
In the diagnosis of lung cancer, pulmonologists have several tools at their disposal. From the tried and true convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration to robotic bronchoscopy for peripheral lesions and new technology to unblind the biopsy tools, this article elucidates and expounds on the tools currently available and being developed for lung cancer diagnosis.
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47
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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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48
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Kent AJ, Byrnes KA, Chang SH. State of the Art: Robotic Bronchoscopy. Semin Thorac Cardiovasc Surg 2020; 32:1030-1035. [PMID: 32846232 DOI: 10.1053/j.semtcvs.2020.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/08/2020] [Accepted: 08/15/2020] [Indexed: 12/25/2022]
Abstract
Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements.
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Affiliation(s)
- Amie J Kent
- Department of Cardiothoracic Surgery, New York University Langone Health, New York NY, USA.
| | - Kim A Byrnes
- Nova Southeastern University Dr. Kiran C. Patel School of Osteopathic Medicine
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, New York University Langone Health, New York NY, USA
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49
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Chen AC, Pastis NJ, Mahajan AK, Khandhar SJ, Simoff MJ, Machuzak MS, Cicenia J, Gildea TR, Silvestri GA. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest 2020; 159:845-852. [PMID: 32822675 PMCID: PMC7856527 DOI: 10.1016/j.chest.2020.08.2047] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background The diagnosis of peripheral pulmonary lesions (PPL) continues to present clinical challenges. Despite extensive experience with guided bronchoscopy, the diagnostic yield has not improved significantly. Robotic-assisted bronchoscopic platforms have been developed potentially to improve the diagnostic yield for PPL. Presently, limited data exist that evaluate the performance of robotic systems in live human subjects. Research Question What is the safety and feasibility of robotic-assisted bronchoscopy in patients with PPLs? Study Design and Methods This was a prospective, multicenter pilot and feasibility study that used a robotic bronchoscopic system with a mother-daughter configuration in patients with PPL 1 to 5 cm in size. The primary end points were successful lesion localization with the use of radial probe endobronchial ultrasound (R-EBUS) imaging and incidence of procedure related adverse events. Robotic bronchoscopy was performed in patients with the use of direct visualization, electromagnetic navigation, and fluoroscopy. After the use of R-EBUS imaging, transbronchial needle aspiration was performed. Rapid on-site evaluation (ROSE) was used on all cases. Transbronchial needle aspiration alone was sufficient when ROSE was diagnostic; when ROSE was not diagnostic, transbronchial biopsy was performed with the use of the robotic platform, followed by conventional guided bronchoscopic approaches at the discretion of the investigator. Results Fifty-five patients were enrolled at five centers. One patient withdrew consent, which left 54 patients for data analysis. Median lesion size was 23 mm (interquartile range, 15 to 29 mm). R-EBUS images were available in 53 of 54 cases. Lesion localization was successful in 51 of 53 patients (96.2%). Pneumothorax was reported in two of 54 of the cases (3.7%); tube thoracostomy was required in one of the cases (1.9 %). No additional adverse events occurred. Interpretation This is the first, prospective, multicenter study of robotic bronchoscopy in patients with PPLs. Successful lesion localization was achieved in 96.2% of cases, with an adverse event rate comparable with conventional bronchoscopic procedures. Additional large prospective studies are warranted to evaluate procedure characteristics, such as diagnostic yield. Clinical Trial Registration ClinicalTrials.gov; No.: NCT03727425; URL: www.clinicaltrials.gov.
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50
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Agrawal A, Hogarth DK, Murgu S. Robotic bronchoscopy for pulmonary lesions: a review of existing technologies and clinical data. J Thorac Dis 2020; 12:3279-3286. [PMID: 32642251 PMCID: PMC7330790 DOI: 10.21037/jtd.2020.03.35] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bronchoscopic interventions are preferred for sampling suspicious pulmonary lesions as they have lower complications and can achieve diagnosis and staging in one single procedure. Limitations in existing guided bronchoscopy platforms has led to developments in robotic assisted technologies. These devices may allow the bronchoscopist to more precisely maneuver the scope and instruments into the periphery of the lungs under direct visualization while also ensuring stability during sampling of the target lesions. These devices have the potential to improve the diagnostic yield in sampling peripheral lung lesions and may play a role in the treatment of non-operable or oligometastatic peripheral tumors using bronchoscopic ablative therapies. In this article, we review the existing robotic bronchoscopy technologies and summarize the available pre-clinical and clinical data supporting their use.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - D Kyle Hogarth
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
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