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

The diagnostic performance and optimal strategy of cone beam CT-assisted bronchoscopy for peripheral pulmonary lesions: A systematic review and meta-analysis

Cone-beam computed tomography (CBCT) assisted bronchoscopy shows prospective advantages in diagnosing peripheral pulmonary lesions (PPLs), but its diagnostic value and potential influencing factors remain unclear. What is the clinical value and optimal strategy of CBCT-assisted bronchoscopy in diagnosing PPLs? The references were searched from PubMed, EmBase, and Web of Science. Studies reporting diagnostic yield and potential influencing factors of CBCT-assisted bronchoscopy were included. The navigational success rate, diagnostic rate, complication rate, and potential influencing factors were pooled by random-effects model and meta-regression. A total of 1,441 patients with 1,540 lesions from 15 studies were included in our meta-analysis. The pooled navigational success rate (97.0% vs 81.6%; odds ratio [OR] 5.12) and diagnostic rate (78.5% vs 55.7%; OR 2.51) of the CBCT-assisted group were significantly higher than those without CBCT. The complication rate of CBCT-assisted bronchoscopy was 4.4% (95%CI: 0.02-0.07). Cone-beam CT combined with r-EBUS can achieve the highest diagnostic rate. Applying positive end-expiratory pressure could improve the diagnostic rate and reduce the complication rate (p < 0.05). Lesions located in the upper lobe could achieve a higher diagnostic rate and lesions located in the right lobes could get a lower complication rate (p < 0.05). Cone-beam CT combined with r-EBUS seems to be the effective and optimal approach to ameliorate the navigation success rate and diagnostic rate of diagnosing PPLs.Clinical trial registration: This study was registered in PROSPERO (Registration Number: CRD42022378992). URL: PROSPERO (york.ac.uk).

Diagnostic performance and safety for robotic-assisted bronchoscopy in pulmonary nodules: a systematic review and meta-analysis

BACKGROUND

Robotic-assisted bronchoscopy (RAB) is an emerging diagnostic tool that combines robotics and bronchoscopy. This meta-analysis aimed to comprehensively evaluate the performance and safety of RAB for pulmonary nodule diagnosis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched from their inception up to 4 November 2024. The quality of the studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2. Random and fixed effects models were used to estimate the pooled diagnosis yield in strict or intermediate criteria, sensitivity for malignancy, and complication rate of RAB in pulmonary nodule diagnosis, with rates (%) and 95% confidence intervals (CIs).

RESULTS

In total, 27 cohort studies were included. The pooled diagnostic yields of RAB for pulmonary nodules were 69.6% (95%CI: 61.8%-76.8%) for strict criteria and 86.6% (95%CI: 83.7%-89.2%) for intermediate criteria, with a sensitivity for malignancy of 85.4% (95%CI: 83.0%-87.7%). The pooled complication rate was estimated to be 3.0% (total pneumothorax, 2.0%; pneumothorax that required intervention, 0.5%; bleeding, 0.1%). The diagnostic yields were different ( P < 0.05) among subgroups of patients based on total number of biopsies (≤100 vs. >100; 83.6% vs. 69.6%), prevalence for malignancy (<60% vs. ≥60%; 66.6% vs. 83.1%), radial endobronchial ultrasound view (concentric vs. eccentric vs. invisible; 88.6% vs. 84.5% vs. 46.0%). A difference ( P = 0.005) in sensitivity for malignancy was observed between the group with average lesion sizes ≤20 mm and the group with sizes >20 mm (86.4% vs. 77.5%).

CONCLUSION

RAB may be effective and safe in pulmonary nodule diagnosis, offering promising prospects for clinical application. The heterogeneity of diagnostic yield may be driven by different diagnostic criteria. Moreover, the current studies of RAB in pulmonary nodule diagnosis are single-arm studies, and more large-scale randomized controlled trials are needed.

Human and Deep Learning Predictions of Peripheral Lung Cancer Using a 1.3 mm Video Endoscopic Probe

BACKGROUND AND OBJECTIVE

Iriscope, a 1.3 mm video endoscopic probe introduced through an r-EBUS catheter, allows for the direct visualisation of small peripheral pulmonary nodules (PPNs). This study assessed the ability of physicians with different levels of experience in bronchoscopy, and the ability of artificial intelligence (AI) to predict the malignant nature of small PPNs during Iriscope peripheral endoscopy.

METHODS

Patients undergoing bronchoscopy with r-EBUS and Iriscope for peripheral PPNs < 20 mm with a definite diagnosis were analysed. Senior and Junior physicians independently interpreted video-recorded Iriscope sequences, classifying them as tumoral (malignant) or non-tumoral, blind to the final diagnosis. A deep learning (DL) model was also trained on Iriscope images and tested on a different set of patients for comparison with human interpretation. Diagnostic accuracy, sensitivity, specificity, and F1 score were calculated.

RESULTS

Sixty-one patients with small PPNs (median size 15 mm, IQR: 11-20 mm) were included. The technique allowed for the direct visualisation of the lesions in all cases. The final diagnosis was cancer for 37 cases and a benign lesion in 24 cases. Senior physicians outperformed junior physicians in recognising tumoral Iriscope images, with a balanced accuracy of 85.4% versus 66.7%, respectively, when compared with the final diagnosis. The DL model outperformed junior physicians with a balanced accuracy of 71.5% but was not superior to senior physicians.

CONCLUSION

Iriscope could be a valuable tool in PPNs management, especially for experienced operators. Applied to Iriscope images, DL could enhance overall performance of less experienced physicians in diagnosing malignancy.

Diagnosing Malignant Epithelial Neoplasms of the Lung in Cytological Specimens: Cytomorphology, Ancillary Studies and Management

The World Health Organization's (WHO) Reporting System for Lung Cytopathology intends to standardise the diagnosing and reporting of cytology specimens from the lung and aims at enhancing the communication between clinicians and (cyto)pathologists. It is closely connected to the 5th edition of the WHO Classification of Thoracic Tumours. The system includes five diagnostic categories, among them the 'Malignant' diagnostic category that incorporates both primary malignant tumours and metastases. Advancements in bronchoscopy have notably improved the diagnostic capacity of cytological specimens that represent the sole source of tumour material in approximately 40% of all lung carcinoma cases. An accurate diagnosis of malignancy and treatment-guiding classification into specific tumour types and subtypes can reliably be achieved with cytology specimens. They additionally serve as an excellent source for predictive immunocytochemistry (ICC) and molecular testing for targetable oncogenic alterations. This review article provides an overview of the key cytopathological features defining the 'Malignant' category of the WHO Reporting System for Lung Cytopathology for non-small cell carcinomas, neuroendocrine neoplasms and other specific carcinomas and malignancies which can be encountered in cytological specimens of the lung. It further describes the application of ancillary techniques, such as ICC and molecular testing, that have been successfully incorporated into different cytological sample types using various preparation methods.

Endobronchial Ultrasound Staging During Navigation Bronchoscopy for Peripheral Pulmonary Nodules in the Real World: Which Patients Will Benefit?

BACKGROUND/OBJECTIVES

The prevalence of lung cancer in patients with a peripheral pulmonary nodule referred for navigation bronchoscopy (NB) is high. Combining NB with a systematic EBUS for staging is common practice. We investigated the added value of performing EBUS in the population referred for NB in relation to the available pre-procedural [18F]FDG-PET and CT imaging information.

METHODS

This single-center study evaluated all consecutive patients who underwent an NB in an academic referral center. [18F]FDG-PET and CT scoring of lymphadenopathy was based on routine [18F]FDG-PET and/or contrast-enhanced chest (ce) CT imaging reports and were correlated to outcome of systematic EBUS and subsequent surgery (when available).

RESULTS

In total, 403 patients were included for analysis of which 327 underwent EBUS (81.1%). In 138/403 patients (35%) who had positive lymph nodes on [18F]FDG-PET (86.5%) or ceCT (13.5%), 12 lung cancer patients were diagnosed with N+ disease by EBUS (8.4%). An additional nine EBUS-negative patients were diagnosed with N+ disease after surgery (5.4%). In the group of patients with imaging-negative lymph nodes (65.8%), no metastatic lymph nodes were found by EBUS, and surgery revealed occult nodal metastasis in eight patients (3.1%).

CONCLUSIONS

In patients with peripheral pulmonary nodules referred for NB, EBUS may be safely omitted when [18F]FDG-PET or ceCT imaging does not indicate presence of nodal involvement.

Artificial intelligence in bronchoscopy: a systematic review

BACKGROUND

Artificial intelligence (AI) systems have been implemented to improve the diagnostic yield and operators' skills within endoscopy. Similar AI systems are now emerging in bronchoscopy. Our objective was to identify and describe AI systems in bronchoscopy.

METHODS

A systematic review was performed using MEDLINE, Embase and Scopus databases, focusing on two terms: bronchoscopy and AI. All studies had to evaluate their AI against human ratings. The methodological quality of each study was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

1196 studies were identified, with 20 passing the eligibility criteria. The studies could be divided into three categories: nine studies in airway anatomy and navigation, seven studies in computer-aided detection and classification of nodules in endobronchial ultrasound, and four studies in rapid on-site evaluation. 16 were assessment studies, with 12 showing equal performance and four showing superior performance of AI compared with human ratings. Four studies within airway anatomy implemented their AI, all favouring AI guidance to no AI guidance. The methodological quality of the studies was moderate (mean MERSQI 12.9 points, out of a maximum 18 points).

INTERPRETATION

20 studies developed AI systems, with only four examining the implementation of their AI. The four studies were all within airway navigation and favoured AI to no AI in a simulated setting. Future implementation studies are warranted to test for the clinical effect of AI systems within bronchoscopy.

[DGP and ÖGP Congress 2024: Highlights from Interventional Pulmonology]

This article summarises the highlights in the field of interventional pneumology from the congresses of the German Society of Pneumology (DGP) in March 2024 and the Austrian Society of Pneumology (ÖGP) in September 2024. Developments and numerous studies in the field of endoscopy and interventional pneumology were presented in the diverse programmes of these two congresses. New bronchoscopic techniques for the diagnosis of mediastinal lymphadenopathy were discussed, innovative navigation techniques and the use of new imaging techniques for the diagnosis of peripheral pulmonary nodules were presented and knowledge in the field of endoscopic lung volume reduction in emphysema patients was expanded.

ERS Congress 2024: highlights from the Thoracic Oncology Assembly

#ERSCongress 2024: highlights from the Thoracic Oncology Assembly (@oncology_ERS) https://bit.ly/42vNDmp.

Diagnostic performance of rapid on-site evaluation during bronchoscopy for lung cancer: A comprehensive meta-analysis

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality worldwide. Screening high-risk populations for lung cancer with low-dose computed tomography (LDCT) reduces lung cancer mortality. Bronchoscopy is a diagnostic procedure used to monitor patients suspected of having lung cancer after LDCT. Rapid on-site evaluation (ROSE) can improve the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), although its diagnostic value remains unclear. In this meta-analysis, the authors evaluated the diagnostic accuracy of ROSE during bronchoscopy.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for studies evaluating the diagnostic accuracy of ROSE for lung cancer during bronchoscopy. Studies evaluating the performance of ROSE and articles providing sufficient data for constructing a 2 × 2 table on a per-lesion basis were included. A meta-analysis was conducted using a bivariate random-effects model.

RESULTS

In total, 32 studies involving 8243 lung lesions were included with a pooled sensitivity of 91.8% and a pooled specificity of 94.9%. Subgroup analysis of 12 studies involving 2929 specimens from patients who underwent computed tomography revealed a pooled sensitivity of 93.8% and a pooled specificity of 96%. Further subgroup analysis of seven studies on the diagnostic outcomes of ROSE for intrathoracic or mediastinal lymph nodes through EBUS-TBNA for lung cancer staging revealed a pooled sensitivity of 90.1% and a pooled specificity of 96.9%.

CONCLUSIONS

ROSE exhibited high sensitivity and specificity for diagnosing lung cancer during bronchoscopy. It also exhibited high sensitivity in detecting lung cancer in patients undergoing LDCT and higher specificity for nodal staging with EBUS-TBNA.

Cryoprobe biopsy versus mechanical biopsies in pulmonary diagnostics

PURPOSE OF REVIEW

Biopsy tools have been essential in improving the diagnostic accuracy of bronchoscopic procedures. Of these tools, cryobiopsy has emerged as a promising technique for diagnosing thoracic diseases. This review summarizes the existing data comparing cryobiopsies to other mechanical biopsy methods for sampling endobronchial, parenchymal, and mediastinal targets.

RECENT FINDINGS

Initially adopted for managing airway stenoses, the use of cryoprobes has expanded to diagnosing endobronchial lesions, parenchymal opacities, and mediastinal lymph node pathologies. Studies have demonstrated that cryobiopsy offers a higher diagnostic yield than forceps biopsy alone. By leveraging the Joule-Thomson effect to freeze and collect larger tissue samples compared to traditional methods, cryobiopsy improves diagnostic accuracy and helps in better characterizing the nature of the lesions. While the risk of complications, such as pneumothorax and hemorrhage are comparable to, or higher than traditional biopsy methods, cryobiopsy's enhanced diagnostic capabilities make it a valuable tool in the assessment of pulmonary disease.

SUMMARY

Compared with other mechanical biopsy techniques, cryoprobe biopsies significantly enhance the diagnostic yield for endobronchial lesions, interstitial lung disease, pulmonary nodules, and mediastinal lymph nodes.

First in Human Evaluation of a Novel Thin Convex Probe Endobronchial Ultrasound System

INTRODUCTION

The incidence of pulmonary imaging abnormalities continues to increase. While standard convex probe endobronchial ultrasound bronchoscope (CP-EBUS) is safe and accurate, it has limited reach through smaller bronchi. Olympus BF-Y0069 thin convex probe EBUS (TCP-EBUS) has a smaller diameter and improved angulation. We assessed the safety and feasibility of the TCP-EBUS to evaluate lesions not accessible with CP-EBUS.

METHODS

A single-center, prospective, pilot study evaluating TCP-EBUS enrolled patients undergoing bronchoscopy for lesions within the inner two-thirds of the lung. Patients underwent CP-EBUS to attempt visualization and biopsy. If unsuccessful, TCP-EBUS was used. Safety, lesion characteristics, and pathology results were collected.

RESULTS

Fifty-one patients were enrolled with multiple lesion locations and no adverse safety events with TCP-EBUS. Seven cases (13.7%) were omitted as the target lesion was visualized by CP-EBUS and TCP-EBUS. CP-EBUS failed to provide biopsy for 44 cases. CP-EBUS visualized 7/44, however, was unable to biopsy. TCP-EBUS visualized 36/44 (81.8%) lesions and biopsied 27/44 (61%) lesions. 8/44 (15.7%) lesions could not be visualized with either device. Median lesion size biopsied with CP-EBUS was 41 mm (IQR: 22-48). Median size of lesions visualized with TCP-EBUS was 20 mm (IQR: 15.3-38), range 8-70. The median distance from the main carina was 62 mm (IQR: 60-89) for lesions biopsied with the CP-EBUS and 63.3 (IQR: 48.5-78.8) for TCP-EBUS. While average distances from main carina were similar in both groups, the furthest lesion TCP-EBUS visualized was 120 mm from the carina compared to 100 mm with CP-EBUS.

CONCLUSIONS

The use of TCP-EBUS was safe and effective without observed patient-associated complications, and it provided real-time ultrasonographic visualization and biopsy of lesions not accessible with CP-EBUS.

Surgeon-led Point-of-care Ultrasound-guided Thoracic Biopsy: A new paradigm in efficient diagnosis and resource-sparing care

OBJECTIVE

Tissue diagnosis through a variety of interventional approaches guides thoracic cancer management, but often introduces delay to definitive treatment and can be resource intensive. We introduced a thoracic surgeon-led, point-of-care ultrasound-guided biopsy program to provide rapid diagnosis for patients with thoracic cancers. We assessed the diagnostic yield and adverse events with this approach.

METHODS

A prospective cohort study was performed of consecutive patients undergoing ultrasound-guided biopsies performed by 5 thoracic surgeons from June 2021 to April 2024 at a tertiary Canadian thoracic surgery institution. By using a bedside ultrasound, 20-gauge tissue cores were obtained using multiple passes with a standard spinal needle. Descriptive univariable statistics were used.

RESULTS

A total of 160 patients underwent bedside biopsy for lung (n = 101), liver (n = 20), chest wall/pleural (n = 20), mediastinal (n = 18), or other (n = 1) lesions. Tissue diagnosis was obtained in 86.3% of patients (n = 138), and diagnostic yield was similar for high- and low-volume providers and over time. All liver biopsies were diagnostic. Nondiagnostic biopsies were more likely to occur with benign pathology, chest wall/pleural lesions, or extensive necrosis; diagnosis was achieved with other modalities in most cases. There was 1 postprocedure pneumothorax (adverse event rate 0.6%).

CONCLUSIONS

Thoracic surgeon-led ultrasound-guided biopsies are safe in an outpatient clinic setting and have high diagnostic accuracy. This results in reduced time to diagnosis by an estimated 28 to 35 days and frees up endoscopic and radiology resources for other patients. This low-cost procedure can be adopted as part of comprehensive thoracic malignancy assessment and can accelerate patient access to cancer treatment.

Novel Strategies for Lung Cancer Interventional Diagnostics

Lung cancer is a major global health issue, with 2.21 million cases and 1.80 million deaths reported in 2020. It is the leading cause of cancer death worldwide. Most lung cancers have been linked to tobacco use, with changes in cigarette composition over the years contributing to shifts in cancer types and tumor locations within the lungs. Additionally, there is a growing incidence of lung cancer among never-smokers, particularly in East Asia, which is expected to increase the global burden of the disease. The classification of non-small cell lung cancer (NSCLC) into distinct subtypes is crucial for treatment efficacy and patient safety, especially as different subtypes respond differently to chemotherapy. For instance, certain chemotherapeutic agents are more effective for adenocarcinoma than for squamous carcinoma, which has led to the exclusion of squamous carcinoma from treatments like Bevacizumab due to safety concerns. This necessitates accurate histological diagnosis, which requires sufficient tissue samples from biopsies. However, acquiring adequate tissue is challenging due to the complex nature of lung tumors, patient comorbidities, and potential complications from biopsy procedures, such as bleeding, pneumothorax, and the purported risk of local recurrence. The need for improved diagnostic techniques has led to the development of advanced technologies like electromagnetic navigation bronchoscopy (ENB), radial endobronchial ultrasound (rEBUS), and robotic bronchoscopy. ENB and rEBUS have enhanced the accuracy and safety of lung biopsies, particularly for peripheral lesions, but both have limitations, such as the dependency on the presence of a bronchus sign. Robotic bronchoscopy, which builds on ENB, offers greater maneuverability and stability, improving diagnostic yields. Additionally, new imaging adjuncts, such as Cone Beam Computed Tomography (CBCT) and augmented fluoroscopy, further enhance the precision of these procedures by providing real-time, high-resolution imaging. These advancements are crucial as lung cancer is increasingly being detected at earlier stages due to screening programs, which require minimally invasive, accurate diagnostic methods to improve patient outcomes. This review aims to provide a comprehensive overview of the current challenges in lung cancer diagnostics and the innovative technological advancements in this rapidly evolving field, which represents an increasingly exciting career path for aspiring pulmonologists.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

AeroPath: An airway segmentation benchmark dataset with challenging pathology and baseline method

To improve the prognosis of patients suffering from pulmonary diseases, such as lung cancer, early diagnosis and treatment are crucial. The analysis of CT images is invaluable for diagnosis, whereas high quality segmentation of the airway tree are required for intervention planning and live guidance during bronchoscopy. Recently, the Multi-domain Airway Tree Modeling (ATM'22) challenge released a large dataset, both enabling training of deep-learning based models and bringing substantial improvement of the state-of-the-art for the airway segmentation task. The ATM'22 dataset includes a large group of COVID'19 patients and a range of other lung diseases, however, relatively few patients with severe pathologies affecting the airway tree anatomy was found. In this study, we introduce a new public benchmark dataset (AeroPath), consisting of 27 CT images from patients with pathologies ranging from emphysema to large tumors, with corresponding trachea and bronchi annotations. Second, we present a multiscale fusion design for automatic airway segmentation. Models were trained on the ATM'22 dataset, tested on the AeroPath dataset, and further evaluated against competitive open-source methods. The same performance metrics as used in the ATM'22 challenge were used to benchmark the different considered approaches. Lastly, an open web application is developed, to easily test the proposed model on new data. The results demonstrated that our proposed architecture predicted topologically correct segmentations for all the patients included in the AeroPath dataset. The proposed method is robust and able to handle various anomalies, down to at least the fifth airway generation. In addition, the AeroPath dataset, featuring patients with challenging pathologies, will contribute to development of new state-of-the-art methods. The AeroPath dataset and the web application are made openly available.

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

INTRODUCTION

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

METHODS

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

CONCLUSION

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

INTRODUCTION

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

METHODS

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

CONCLUSION

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

Nanoscale Extracellular Vesicle-Enabled Liquid Biopsy: Advances and Challenges for Lung Cancer Detection

Lung cancer is responsible for the death of over a million people worldwide every year. With its high mortality rate and exponentially growing number of new cases, lung cancer is a major threat to public health. The high mortality and poor survival rates of lung cancer patients can be attributed to its stealth progression and late diagnosis. For a long time, intrusive tissue biopsy has been considered the gold standard for lung cancer diagnosis and subtyping; however, the intrinsic limitations of tissue biopsy cannot be overlooked. In addition to being invasive and costly, it also suffers from limitations in sensitivity and specificity, is not suitable for repeated sampling, provides restricted information about the tumor and its molecular landscape, and is inaccessible in several cases. To cope with this, advancements in diagnostic technologies, such as liquid biopsy, have shown great prospects. Liquid biopsy is an innovative non-invasive approach in which cancer-related components called biomarkers are detected in body fluids, such as blood, urine, saliva and others. It offers a less invasive alternative with the potential for applications such as routine screening, predicting treatment outcomes, evaluating treatment effectiveness, detecting residual disease, or disease recurrence. A large number of research articles have indicated extracellular vesicles (EVs) as ideal biomarkers for liquid biopsy. EVs are a heterogeneous collection of membranous nanoparticles with diverse sizes, contents, and surface markers. EVs play a critical role in pathophysiological states and have gained prominence as diagnostic and prognostic biomarkers for multiple diseases, including lung cancer. In this review, we provide a detailed overview of the potential of EV-based liquid biopsy for lung cancer. Moreover, it highlights the strengths and weaknesses of various contemporary techniques for EV isolation and analysis in addition to the challenges that need to be addressed to ensure the widespread clinical application of EV-based liquid biopsies for lung cancer. In summary, EV-based liquid biopsies present interesting opportunities for the development of novel diagnostic and prognostic platforms for lung cancer, one of the most abundant cancers responsible for millions of cancer-related deaths worldwide.

Navigated ultrasound bronchoscopy with integrated positron emission tomography-A human feasibility study

BACKGROUND AND OBJECTIVE

Patients suspected to have lung cancer, undergo endobronchial ultrasound bronchoscopy (EBUS) for the purpose of diagnosis and staging. For presumptive curable patients, the EBUS bronchoscopy is planned based on images and data from computed tomography (CT) images and positron emission tomography (PET). Our study aimed to evaluate the feasibility of a multimodal electromagnetic navigation platform for EBUS bronchoscopy, integrating ultrasound and segmented CT, and PET scan imaging data.

METHODS

The proof-of-concept study included patients with suspected lung cancer and pathological mediastinal/hilar lymph nodes identified on both CT and PET scans. Images obtained from these two modalities were segmented to delineate target lymph nodes and then incorporated into the CustusX navigation platform. The EBUS bronchoscope was equipped with a sensor, calibrated, and affixed to a 3D printed click-on device positioned at the bronchoscope's tip. Navigation accuracy was measured postoperatively using ultrasound recordings.

RESULTS

The study enrolled three patients, all presenting with suspected mediastinal lymph node metastasis (N1-3). All PET-positive lymph nodes were displayed in the navigation platform during the EBUS procedures. In total, five distinct lymph nodes were sampled, yielding malignant cells from three nodes and lymphocytes from the remaining two. The median accuracy of the navigation system was 7.7 mm.

CONCLUSION

Our study introduces a feasible multimodal electromagnetic navigation platform that combines intraoperative ultrasound with preoperative segmented CT and PET imaging data for EBUS lymph node staging examinations. This innovative approach holds promise for enhancing the accuracy and effectiveness of EBUS procedures.

Improving Radial EBUS Signal with Creation of False Airway to Target Lesion During Electromagnetic Navigational Bronchoscopy: A Case Series

Navigational bronchoscopy is increasingly used to target peripheral pulmonary nodules using electromagnetic navigational platforms (ENB), fluoroscopic navigation, or robotic-assisted bronchoscopy. The selection of equipment largely depends on the availability of technology, expertise, and the characteristics of the nodule and patient. Radial EBUS (r-EBUS) is often combined with these techniques for real-time confirmation of the nodule location. A bronchus sign is considered to have a higher diagnostic yield when biopsy tools can directly reach the nodule. We describe a case series of creating a false airway into the nodule when an eccentric r-EBUS signal is seen to subsequently obtain a concentric signal.

Bronchoscopy with and without needle-based confocal laser endomicroscopy for peripheral lung nodule diagnosis: protocol for a multicentre randomised controlled trial (CLEVER trial)

INTRODUCTION

Despite many technological advances, the diagnostic yield of bronchoscopic peripheral lung nodule analysis remains limited due to frequent mispositioning. Needle-based confocal laser endomicroscopy (nCLE) enables real-time microscopic feedback on needle positioning, potentially improving the sampling location and diagnostic yield. Previous studies have defined and validated nCLE criteria for malignancy, airway and lung parenchyma. Larger studies demonstrating the effect of nCLE on diagnostic yield are lacking. We aim to investigate if nCLE-imaging integrated with conventional bronchoscopy results in a higher diagnostic yield compared with conventional bronchoscopy without nCLE.

METHODS AND ANALYSIS

This is a parallel-group randomised controlled trial. Recruitment is performed at pulmonology outpatient clinics in universities and general hospitals in six different European countries and one hospital in the USA. Consecutive patients with a for malignancy suspected peripheral lung nodule (10-30 mm) with an indication for diagnostic bronchoscopy will be screened, and 208 patients will be included. Web-based randomisation (1:1) between the two procedures will be performed. The primary outcome is diagnostic yield. Secondary outcomes include diagnostic sensitivity for malignancy, needle repositionings, procedure and fluoroscopy duration, and complications. Pathologists will be blinded to procedure type; patients and endoscopists will not.

ETHICS AND DISSEMINATION

Primary approval by the Ethics Committee of the Amsterdam University Medical Center. Dissemination involves publication in a peer-reviewed journal.

SUPPORT

Financial and material support from Mauna Kea Technologies.

TRIAL REGISTRATION NUMBER

NCT06079970.

Diagnostic yield and safety of diagnostic techniques for pulmonary lesions: systematic review, meta-analysis and network meta-analysis

BACKGROUND

With recent advancements in bronchoscopic procedures, data on the best modality to sample peripheral pulmonary lesions (PPLs) is lacking, especially comparing bronchoscopy with computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA).

METHODS

We performed a meta-analysis, pairwise meta-analysis and network meta-analysis on studies reporting diagnostic yield and complications with the use of CT-TBNA, radial endobronchial ultrasound (rEBUS), virtual bronchoscopy (VB), electromagnetic navigation (EMN) or robot-assisted bronchoscopy (RAB) to sample PPLs. The primary outcome was diagnostic yield and the secondary outcome was complications. We estimated the relative risk ratios using a random-effects model and used the frequentist approach for the network meta-analysis. We performed extensive analysis to assess the heterogeneity including reporting bias, publication bias, subgroup and meta-regressional analysis. We assessed the quality of the studies using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) and QUADAS-Comparative (QUADAS-C).

RESULTS

We included 363 studies. The overall pooled diagnostic yield was 78.1%, the highest with CT-TBNA (88.9%), followed by RAB (84.8%) and the least with rEBUS (72%). In the pairwise meta-analysis, only rEBUS showed inferiority to CT-TBNA. The network meta-analysis ranked CT-TBNA as likely the most effective approach followed by VB, EMN and RAB, while rEBUS was the least effective, with a low-GRADE certainty. CT-TBNA had the highest rate of complications.

CONCLUSION

Although CT-TBNA is the most effective approach to sample PPLs, RAB has a comparable diagnostic yield with a lesser complication rate. Further prospective studies are needed comparing CT-TBNA and RAB.

Diagnostic yield of cone beam CT based navigation bronchoscopy in patients with metastatic lesions: A propensity score matched case-control study

BACKGROUND

Cone beam CT based Navigation Bronchoscopy (CBCT-NB) has predominantly been investigated as a diagnostic tool in (suspected) primary lung cancers. Small metastatic lesions are clinically considered more challenging to diagnose, but no study has explored the yield of navigation bronchoscopy in patients with pulmonary metastatic lesions (ML) compared to primary lung cancers (PL), correcting for known lesion characteristics affecting diagnostic yield.

MATERIALS AND METHODS

This is a single-center, retrospective, propensity score-matched case-control study. We matched a subset of patients who underwent CBCT-NB and received a final diagnosis of pulmonary metastases of solid tumors between December 2017 and 2021 against confirmed primary lung cancer lesions subjected to CBCT-NB in the same time period. The lesions were propensity score matched based on known characteristics affecting yield, including location (upper lobe, lower lobe), size, bronchus sign, and lesion solidity.

RESULTS

Fifty-six metastatic pulmonary lesions (mean size 14.7 mm) were individually case-matched to a selection of 297 available primary lung cancer lesions. Case-matching revealed non-significant differences in navigation success rate (PL: 89.3 % vs. ML: 82.1 %, 95%CI on differences: -21.8 to +7.5) and yield (PL: 60.7 % vs. ML: 55.4 %, 95%CI on differences: -25.4 to +14.7). The overall complication rate was comparable (5.4 % in PL vs. 5,4 % in ML).

CONCLUSION

After matching primary and metastatic lesions based on CT assessable lesions characteristics, CBCT-NB showed no clinically relevant or significantly different navigation success or yield in either group. We recommend a careful assessment of CT characteristics to determine procedural difficulty rather than selecting based on the suspicion of lesion origin.

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

RATIONALE AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Rapid on-site evaluation of touch imprint cytology in navigation bronchoscopy for small peripheral pulmonary nodules

BACKGROUND

Rapid on-site evaluation (ROSE) of cytopathology plays an important role in determining whether representative samples have been taken during navigation bronchoscopy. With touch imprint cytology (TIC), histologic samples can be assessed using ROSE. Although advised by guidelines, there have been almost no studies on the performance of TIC during navigation bronchoscopy. The objective of this study was to evaluate the value of TIC-ROSE (forceps/cryobiopsy) in combination with conventional ROSE (cytology needle/brush).

METHODS

In this single-center, prospective cohort study, patients who had pulmonary nodules with an indication for navigation bronchoscopy were consecutively included. The primary outcome of the study was the concordance of ROSE and the procedural outcome. The concordance rates of TIC-ROSE and the combination of TIC-ROSE plus conventional ROSE were compared.

RESULTS

Fifty-eight patients with 66 nodules were included. Conventional ROSE and TIC-ROSE were assessable in 61 nodules (90.9%) each. By combining both ROSE techniques, all sampled lesions were assessable. Combining conventional ROSE with TIC-ROSE showed concordant results in 51 of 66 cases (77.3%) versus 44 of 66 (66.7%) and 48 of 66 (72.8%) concordant results for conventional ROSE and TIC-ROSE alone, respectively, compared with the procedural outcome. There was no indication of tissue depletion as a result of TIC. The combined ROSE approach had a statistically significant higher concordance rate compared with conventional ROSE alone.

CONCLUSIONS

TIC-ROSE is a cheap, easily implementable technique that can result in higher concordant ROSE outcomes. This could lead to more efficient procedures and possibly higher diagnostic results. In a monomodality sampling setting with only histologic samples, TIC can provide ROSE.

Electromagnetic Navigational Bronchoscopy Learning Curve Regarding Pneumothorax Rate and Diagnostic Yield

Electromagnetic navigational bronchoscopy (ENB) has emerged as an innovative technique for diagnosing peripheral and central nodules, offering an improved diagnostic yield compared to conventional bronchoscopy with fewer complications. That being said, pneumothorax remains a frequent complication. This retrospective study conducted at Castle Hill Hospital, UK, analysed ENB procedures over four years to assess the diagnostic yield and pneumothorax rates, exploring learning curves and procedural improvements specifically focusing on the diagnostic yield and pneumothorax rate as markers of change. A total of 246 patients underwent 358 peripheral lung biopsies, revealing an overall diagnostic yield of 61.3%. The diagnostic yield increased from 58.2% in 2020-2021 to 66.0% in 2022-2023 while the pneumothorax rate decreased significantly from 9.8% to 3.4% (p = 0.021*). The majority of pneumothorax cases occurred following upper lobe procedures. The study depicts the importance of procedural experience in improving outcomes, suggesting a learning curve effect. Additionally, it emphasizes the potential for technological advancements, such as robotic assistance, to mitigate operator-dependent variability and improve reproducibility in ENB procedures. These findings contribute to optimizing diagnostic pathways for lung lesions and improving patient safety in ENB interventions.

Cone-beam CT imaging for robotic navigation bronchoscopy

See related article

Assessment of Advanced Diagnostic Bronchoscopy Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American College of Chest Physicians Research Statement

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

Imaging modalities during navigational bronchoscopy

INTRODUCTION

Lung nodules are commonly encountered in clinical practice. Technological advances in navigational bronchoscopy and imaging modalities have led to paradigm shift from nodule screening or follow-up to early lung cancer detection. This is due to improved nodule localization and biopsy confirmation with combined modalities of navigational platforms and imaging tools. To conduct this article, relevant literature was reviewed via PubMed from January 2014 until January 2024.

AREAS COVERED

This article highlights the literature on different imaging modalities combined with commonly used navigational platforms for diagnosis of peripheral lung nodules. Current limitations and future perspectives of imaging modalities will be discussed.

EXPERT OPINION

The development of navigational platforms improved localization of targets. However, published diagnostic yield remains lower compared to percutaneous-guided biopsy. The discordance between the actual location of lung nodule during the procedure and preprocedural CT chest is the main factor impacting accurate biopsies. The utilization of advanced imaging tools with navigation-based bronchoscopy has been shown to assist with localizing targets in real-time and improving biopsy success. However, it is important for interventional bronchoscopists to understand the strengths and limitations of these advanced imaging technologies.

Robotic-assisted bronchoscopy for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis

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.

An International Survey of Practices in the Investigation and Endoscopic Treatment of Peripheral Pulmonary Lesions amongst Interventional Bronchoscopists

INTRODUCTION

The investigation of peripheral pulmonary lesions (PPLs) can be challenging. Several bronchoscopic modalities have been developed to reach and biopsy PPL but the level of adoption of these techniques by interventional pulmonologists (IPs) is unknown. This international survey was conducted to describe current practices in PPL investigation among IP.

METHODS

This survey was sent to all members of the World Association for Bronchology and Interventional Pulmonology, Canadian Thoracic Society Procedures Assembly, AABIP, and the Groupe d'Endoscopie Thoracique et Interventionnel Francophone. The survey was composed of 48 questions and three clinical cases to establish a portrait of modalities used to investigate and treat PPL by IP around the world.

RESULTS

Three hundred and twelve IP responded to the survey. Most of them practice in Europe (n = 122), North America (n = 97), and Asia (n = 49). Half of responders perform more than 100 endoscopic procedures for PPL annually. General anesthesia and conscious sedation are used in similar proportions (53% and 47%, respectively). Rapid on site evaluation (ROSE) is used when sampling PPL by 42%. Radial EBUS (69%), fluoroscopy (55%), and electromagnetic navigation (27%) are the most widely used techniques. Most IP combine techniques (89%). Robotic bronchoscopy (15%) and cone-beam CT (8%) are almost exclusively used in the USA where, respectively, 60% and 37% of respondents reported using these modalities. Ten percent of IP currently had access to endoscopic treatment modalities for PPL. However, half of the remaining IP plan to acquire an endoscopic treatment modality in the next 2 years.

CONCLUSION

Available techniques and practices worldwide vary significantly regarding PPL investigation and treatment.

ERS International Congress 2023: highlights from the Clinical Techniques, Imaging and Endoscopy Assembly

The Clinical Techniques, Imaging and Endoscopy Assembly is involved in the diagnosis and treatment of several pulmonary diseases, as demonstrated at the 2023 European Respiratory Society (ERS) International Congress in Milan, Italy. From interventional pulmonology, the congress included several exciting results for the use of bronchoscopy in lung cancer, including augmented fluoroscopy, robotic-assisted bronchoscopy and cryobiopsies. In obstructive lung disease, the latest results on bronchoscopic treatment of emphysema with hyperinflation and chronic bronchitis were presented. Research on using cryobiopsies to diagnose interstitial lung disease was further explored, with the aims of elevating diagnostic yield and minimising risk. For imaging, the latest updates in using artificial intelligence to overcome the increased workload of radiologists were of great interest. Novel imaging in sarcoidosis explored the use of magnetic resonance imaging, photon-counting computed tomography and positron emission tomography/computed tomography in the diagnostic work-up. Lung cancer screening is still a hot topic and new results were presented regarding incorporation of biomarkers, identifying knowledge gaps and improving screening programmes. The use of ultrasound in respiratory medicine is an expanding field, which was demonstrated by the large variety in studies presented at the 2023 ERS Congress. Ultrasound of the diaphragm in patients with amyotrophic lateral sclerosis and myasthenia gravis was used to assess movements and predict respiratory fatigue. Furthermore, studies using ultrasound to diagnose or monitor pulmonary disease were presented. The congress also included studies regarding the training and assessment of competencies as an important part of implementing ultrasound in clinical practice.

Ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions

Bronchoscopes are continuously improving. Increasingly, thinner bronchoscopes with larger working channels and better imaging quality are becoming available for clinical use. Concurrently, useful ancillary devices have been developed, such as radial probe endobronchial ultrasound (rEBUS) and navigation devices. Randomized studies have demonstrated the diagnostic superiority of ultrathin bronchoscopy over thin bronchoscopy under rEBUS and virtual bronchoscopic navigation guidance for small, peripheral pulmonary lesions. Furthermore, biopsy needles and cryoprobes have been miniaturized and adapted to the working channel of the new ultrathin bronchoscopes. Multi-modality and multi-instrumental ultrathin bronchoscopy using such new technologies has facilitated high diagnostic yields.

Radial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy versus Forceps Biopsy for the Diagnosis of Solitary Pulmonary Nodules: A Prospective Randomised Trial

Background

Improvements in pulmonary diagnostic imaging and the development of lung cancer screening are increasing the prevalence of Solitary pulmonary nodules (SPNs). Fluoroscopically guided radial endobronchial ultrasound (EBUS) with transbronchial forceps biopsy (TB-FB) has been the conventional diagnostic method. Transbronchial cryobiopsy (TB-CB) is an alternative biopsy method. We sought to compare transbronchial cryobiopsy to transbronchial forceps biopsy for the diagnosis of SPNs.

Methods

A prospective, single-centre, randomised controlled trial was conducted at the Royal Adelaide Hospital (RAH). Patients with SPNs were randomised to either 5 transbronchial forceps biopsies or one transbronchial cryobiopsy. Complete blinding of investigators and participants was not possible, as transbronchial cryobiopsy required general anaesthesia. The primary outcome was diagnostic yield with secondary outcomes of specimen size, diagnostic yield for subsets challenging to access with forceps and safety.

Results

The overall diagnostic yield for the 28 enrolled subjects was 76.8%(22/28). The diagnostic yield was 91.7% (11/12 patients) for transbronchial cryobiopsy and 68.8% (11/16 patients) for forceps biopsy (p=0.14). Median biopsy sizes were consistently larger for the cryobiopsy arm at 7.0mm compared to 2.5mm(p<0.0001). An eccentric EBUS image signalling the probe was adjacent to the nodule occurred in 4/28 cases, and TB-CB confirmed a diagnosis in 3/3 randomised to this arm. There were no major complications with either technique.

Conclusion

Transbronchial cryobiopsy under the guidance of fluoroscopy and radial EBUS facilitates larger biopsy specimens without a significant increase in major complications. Further research is required to confirm the effect on diagnostic yield; however, our study supports a role for TB-CB in the diagnosis of SPNs and small, nodule-adjacent biopsies.

Clinical Trial Registration Number

Reference number of R20160213(HREC/16/RAH/37).

Real-World Impact of Robotic-Assisted Bronchoscopy on the Staging and Diagnosis of Lung Cancer: The Shape of Current and Potential Opportunities

The approach to peripheral pulmonary lesions (PPL) has been evolving continuously. Advanced bronchoscopic navigational techniques have improved the airway-based approaches to these lesions. Robotic Assisted Bronchoscopy (RAB) can be considered the current pinnacle of this evolution; allowing for a safer approach to sampling lesions previously considered outside of bronchoscopic reach. We present a comprehensive review of the changing epidemiology of lung cancer and the importance of early tissue sampling, the evolution of sampling and navigational bronchoscopic techniques, technical considerations and evidence pertaining to the use of RAB, and adjunct techniques in the diagnosis of lung cancer. Complications and future applications of RAB are also discussed.