Reproducibility of peripheral branches in virtual bronchoscopic navigation using VINCENT and LungPoint software for peripheral lung lesions

[Advanced bronchoscopic techniques for the diagnosis of peripheral lung nodule]

The endoscopic diagnosis of peripheral lung nodules is a challenging aspect of oncological practice. More often than not inaccessible by traditional endoscopy, these nodules necessitate multiple imagery tests, as well as diagnostic surgery for benign lesions. Even though transthoracic ultrasonography has a high diagnostic yield, a sizeable complication rate renders it suboptimal. Over recent years, a number of safe and accurate navigational bronchoscopic procedures have been developed. In this first part, we provide an overview of the bronchoscopic techniques currently applied for the excision and diagnostic analysis of peripheral lung nodules; emphasis is laid on electromagnetic navigation bronchoscopy and the association of virtual bronchoscopy planner with radial endobronchial ultrasound. We conclude by considering recent innovations, notably robotic bronchoscopy.

Findings of virtual bronchoscopic navigation can predict the diagnostic rate of primary lung cancer by bronchoscopy in patients with peripheral lung lesions

BACKGROUND

Despite being minimally invasive, bronchoscopy does not always result in pathological specimens being obtained. Therefore, we investigated whether virtual bronchoscopic navigation (VBN) findings were associated with the rate of diagnosis of primary lung cancer by bronchoscopy in patients with peripheral lung lesions.

METHODS

This study included patients with suspected malignant peripheral lung lesions who underwent bronchoscopy at St. Luke's International Hospital between October 2013 and March 2020. Patients diagnosed with primary lung cancer were grouped according to whether their pathology could be diagnosed by bronchoscopy, and their clinical factors were compared. In addition, the distance between the edge of the lesion and the nearest branch ("distance by VBN") was calculated. The distance by VBN and various clinical factors were compared with the diagnostic rates of primary lung cancer.

RESULTS

The study included 523 patients with 578 lesions. After excluding 55 patients who underwent multiple bronchoscopies, 381 patients were diagnosed with primary lung cancer. The diagnostic rate by bronchoscopy was 71.1% (271/381). Multivariate analysis revealed that the lesion diameter (odds ratio [OR] 1.107), distance by VBN (OR 0.94) and lesion structure (solid lesion or ground-glass nodule; OR 2.988) influenced the risk of a lung cancer diagnosis. The area under the receiver operating characteristic curve for diagnosis based on lesion diameter and distance by VBN was 0.810.

CONCLUSION

The distance by VBN and lesion diameter were predictive of the diagnostic rates of primary lung cancer by bronchoscopy in patients with peripheral lung lesions.

The superiority of manual over automated methods in identifying bronchial trees on identical CT images

The purpose of this study was to compare a manual bronchoscopic navigation technique, the direct oblique method (DOM), with conventional virtual bronchoscopic navigation software in terms of bronchial identification ability involving reconstruction of a whole bronchial tree from identical CT images. A whole bronchial tree was drawn using manual bronchial recognition with the DOM. The tree was compared with that reconstructed by SYNAPSE VINCENT bronchoscopic navigation-dedicated software. The number of bronchial generations at each terminal tip was then compared between the two approaches. Physicians spent 20 h tracing all bronchi on CT scan images and obtained a bronchial tree. The hand-made bronchial tree had five times the number of tips as that reconstructed by automatic bronchial recognition (1482 vs. 279 tips, respectively). The number of bronchial generations prior to each terminal tip was larger with the DOM than with VINCENT (median, 10; interquartile range (IQR), 9–11 vs. median, 5; IQR, 5–7, respectively; p-value < 0.001). Using the CT image data in this case, manual bronchial recognition with the DOM identified more bronchi than automatic bronchial recognition. This result implies that manual bronchial recognition is a valid basis for detailed bronchoscopic navigation analysis.

Advances in Diagnostic Bronchoscopy

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.

Epidermal growth factor receptor (EGFR) mutation testing is useful for primary lung cancer diagnosis and appropriate surgical resection: A case series

Primary lung cancer was suspected in three patients upon chest computed tomography (CT) and bronchoscopy. Wash cytology revealed that all patients had lesions categorized as class III or lower (Papanicolaou classification), and the wash solution was then subjected to an epidermal growth factor receptor (EGFR) mutation search. As a result, exon 19 deletion was found in two patients, whereas an exon 21 L858R mutation was found in one. Therefore, all three patients underwent surgery without pathological evidence, and surgical pathology subsequently confirmed the diagnosis of primary lung adenocarcinoma. As observed, EGFR mutation testing was useful for cancer diagnosis.