Improved Diagnostic Yield of Bronchoscopy in a Community Practice: Combination of Electromagnetic Navigation System and Rapid On-site Evaluation

Guided Bronchoscopy for the Evaluation of Pulmonary Lesions: An Updated Meta-analysis

BACKGROUND

Guided bronchoscopy is increasingly used to diagnose peripheral pulmonary lesions (PPLs). A meta-analysis published in 2012 demonstrated a pooled diagnostic yield of 70%; however, recent publications have documented yields as low as 40% and as high as 90%.

RESEARCH QUESTION

Has the diagnostic yield of guided bronchoscopy in patients with PPLs improved over the past decade?

STUDY DESIGN AND METHODS

A comprehensive search was performed of studies evaluating the diagnostic yield of differing bronchoscopic technologies used to reach PPLs. Study quality was assessed using the Quality assessment of diagnostic accuracy of studies (QUADAS-2) assessment tool. Number of lesions, type of technology used, overall diagnostic yield, and yield by size were extracted. Adverse events were recorded. Meta-analytic techniques were used to summarize findings across all studies.

RESULTS

A total of 16,389 lesions from 126 studies were included. There was no significant difference in diagnostic yield prior to 2012 (39 studies; 3,052 lesions; yield 70.5%) vs after 2012 (87 studies; 13,535 lesions; yield 69.2%) (P > .05). Additionally, there was no significant difference in yield when comparing different technologies. Studies with low risk of overall bias had a lower diagnostic yield than those with high risk of bias (66% vs 71%, respectively; P = .018). Lesion size > 2 cm, presence of bronchus sign, and reports with a high prevalence of malignancy in the study population were associated with significantly higher diagnostic yield. Significant (P < .0001) between-study heterogeneity was also noted.

INTERPRETATION

Despite the reported advances in bronchoscopic technology to diagnose PPLs, the diagnostic yield of guided bronchoscopy has not improved.

Evaluation of electromagnetic navigational bronchoscopic biopsy of lung lesions performed by a thoracic surgical service

BACKGROUND

With the increasing use of computed tomography scans for lung cancer screening and surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. Electromagnetic navigational bronchoscopy-guided lung biopsy is a relatively new technique for bronchoscopic biopsy. Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy-guided lung biopsy.

METHODS

We conducted a retrospective review of patients who underwent an electromagnetic navigational bronchoscopy biopsy, performed by a thoracic surgical service, and evaluated its safety and diagnostic accuracy.

RESULTS

In total, 110 patients (men 46, women 64) underwent electromagnetic navigational bronchoscopy sampling of pulmonary lesions (n = 121; median size 27 mm; interquartile range 17-37 mm). There was no procedure-related mortality. Pneumothorax requiring pigtail drainage occurred in 4 patients (3.5%). Ninety-three (76.9%) of the lesions were malignant. Eighty-seven (71.9%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (P = .0578) with a yield of 50% for lesions <2 cm, increasing to 81% for lesions ≥2 cm. The lesions that demonstrated a positive "bronchus sign" had a yield of 87% (45/52) compared with 61% (42/69) in lesions with a negative "bronchus sign" (P = .0359).

CONCLUSION

Thoracic surgeons can perform electromagnetic navigational bronchoscopy safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of a bronchus sign and increasing lesion size. Patients with larger tumors and the bronchus sign may be candidates for this approach to biopsy. Further work is required to define the role of electromagnetic navigational bronchoscopy in the diagnosis of pulmonary lesions.

Electromagnetic navigation bronchoscopy versus virtual bronchoscopy navigation for improving the diagnosis of peripheral lung lesions: analysis of the predictors of successful diagnosis

PURPOSE

To investigate if electromagnetic navigation bronchoscopy (ENB) improves the diagnostic yield for peripheral lung lesions from that achieved by virtual bronchoscopy navigation (VBN).

METHODS

This retrospective study compared the results of 100 ENB-transbronchial lung biopsies (TBLBs) with those of 50 VBN-TBLBs at a single institution.

RESULTS

ENB improved the diagnostic yield significantly compared with VBN (64.0% for 19.4 ± 9.0 mm tumors vs. 46.0% for 27.6 ± 8.9 mm tumors; p < 0.0001). Irrespective of the bronchus sign, ENB was more favorable than VBN, with 81.0% (47/58) achieved by ENB vs. 60.0% (21/35) achieved by VBN in the presence of the positive bronchus sign (p = 0.0283), and 40.5% (17/42) achieved by ENB vs. 13.3% (2/15) achieved by VBN in the absence of the bronchus sign (p = 0.0431). Univariate analysis identified tumor size (p = 0.0048), amount of intravenous sedation (p = 0.0182), registration time (p = 0.0111), minimum distance to target (p = 0.0244), and the bronchus sign (p < 0.0001) as factors that affected the yield significantly for ENB. Multivariate analysis identified the bronchus sign (odds ratio 6.74; 95% CI 1.84-24.7) and the registration time (OR 1.01; 95% CI 1.00-1.02) as significant factors.

CONCLUSIONS

Despite the bronchus sign being a significant factor, ENB improved the diagnostic yield of smaller lesions significantly, compared with VBN, regardless of the bronchus sign.

Diagnostic Performance of Electromagnetic Navigation Bronchoscopy-Guided Biopsy for Lung Nodules in the Era of Molecular Testing

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

The Diagnostic Accuracy and Sensitivity for Malignancy of Radial-Endobronchial Ultrasound and Electromagnetic Navigation Bronchoscopy for Sampling of Peripheral Pulmonary Lesions: Systematic Review and Meta-analysis

BACKGROUND

Lung cancer screening with computed tomography chest is identifying peripheral pulmonary lesions (PPLs) suspicious for early-stage lung cancer at increasing rates. Radial-endobronchial ultrasound (R-EBUS) and electromagnetic navigation bronchoscopy (ENB) are 2 methods to sample PPLs to diagnose and treat early lung cancer. ENB has a higher operating financial cost, however, the rationale for its use is possible higher diagnostic accuracy versus R-EBUS.

OBJECTIVE

The objective of this study was to determine the comparative diagnostic accuracy, sensitivity, and negative predictive value for R-EBUS and ENB in sampling PPLs.

METHODS

A systematic review and meta-analysis were conducted. The Ovid Medline database was queried for original research reporting a diagnostic yield of R-EBUS or ENB for PPLs identified on computed tomography chest suspicious for malignancy. The I statistic assessed study heterogeneity. Random effects models produced pooled estimates of diagnostic accuracy and sensitivity for malignancy. Reasons for heterogeneity were explored with meta-regression. Publication bias and small study effects were assessed.

RESULTS

A total of 41 studies involved 2988 lung nodules (R-EBUS 2102, ENB 886) in 3204 patients (R-EBUS 2097, ENB 1107). Overall sensitivity to detect cancer was 70.7% [95% confidence interval (CI): 67.2-74.0]; R-EBUS 70.5% (95% CI: 66.1-74.8), ENB 70.7% (95% CI: 64.7-76.8). Pooled overall diagnostic accuracy was 74.2% (95% CI: 71.0-77.3); R-EBUS 72.4% (95% CI: 68.7-76.1), ENB 76.4% (95% CI: 70.8-82.0). The localization modalities had comparative safety profiles of <2% complications.

CONCLUSION

Both technologies have a high proportion of successful PPL localization with similar sensitivity for malignancy and accuracy. As such, both reasonable options for health care authorities to employ diagnostic algorithms.

Jet Ventilation Decreases Target Motion and Increases Yield of ENB Especially in Lesions With Negative Bronchus Sign

BACKGROUND

Electromagnetic navigational bronchoscopy (ENB) is used to obtain peripheral lung tissue samples for evaluation and staging of central and peripheral lung lesions. Jet ventilation delivers and maintains a sustained airway pressure at high frequency, chest wall and diaphragmatic movement is drastically reduced compared with traditional ventilation. The current study looks to examine the effectiveness of tissue sampling (diagnostic yield) while using jet ventilation on target-lesion movement when compared with traditional ventilation.

METHODS

A total of 36 patients received total intravenous anesthesia with both jet and traditional ventilation during ENB procedure where sensor to lesion displacement was recorded. When planning the ENB procedure, the presence or absence of a viable airway to the lesion was recorded. Sensor to lesion movement was recorded and compared for significance using χ and t tests, utilizing stringent P-values.

RESULTS

Overall patients with an airway to the lesion (n=23) had a higher proportion of successful diagnostic biopsies, 83% compared with those patients that lacked an airway to the lesion (n=13) 70% proportion of successful diagnostic biopsies. When using jet ventilation, the chance of nonzero displacement was 8.3% (0.14 mm), regardless of the presence of an airway. Compared with traditional ventilation, the chance of a nonzero displacement between the sensor and target-lesion was 83% (6.4 mm), independent of airway presence to the lesions.

CONCLUSION

In patients without an airway, jet ventilation significantly decreased target displacement when compared with traditional ventilation (2 vs. 17 mm). In patients with direct airway to the lesion, jet ventilation did not significantly decrease target displacement when compared with the traditional approach.

Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis

BACKGROUND

Bronchoscopy is a useful tool for the diagnosis of lesions near central airways; however, the diagnostic accuracy of these procedures for peripheral pulmonary lesions (PPLs) is a matter of ongoing debate. In this setting, electromagnetic navigation bronchoscopy (ENB) is a technique used to navigate and obtain samples from these lesions. This systematic review and meta-analysis aims to explore the sensitivity of ENB in patients with PPLs suspected of lung cancer.

RESEARCH QUESTION

In patients with peripheral pulmonary lesion suspected of lung cancer, what is the sensitivity and safety of electromagnetic navigation bronchoscopy compared to surgery or longitudinal follow up?

STUDY DESIGN AND METHODS

A comprehensive search of several databases was performed. Extracted data included sensitivity of ENB for malignancy, adequacy of the tissue sample, and complications. The study quality was assessed using the QUADAS-2 tool, and the combined data were meta-analyzed using a bivariate method model. A summary receiver operatic characteristic curve (sROC) was created. Finally, the quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Forty studies with a total of 3,342 participants were included in our analysis. ENB reported a pooled sensitivity of 77% (95% CI, 72%-82%; I² = 80.6%) and a specificity of 100% (95% CI, 99%-100%; I² = 0%) for malignancy. The sROC showed an area under the curve of 0.955 (P = .03). ENB achieved a sufficient sample for ancillary tests in 90.9% (95% CI, 84.8%-96.9%; I² = 80.7%). Risk of pneumothorax was 2.0% (95% CI, 1.0-3.0; I² = 45.2%). We found subgroup differences according to the risk of bias and the number of sampling techniques. Meta-regression showed an association between sensitivity and the mean distance of the sensor tip to the center of the nodule, the number of tissue sampling techniques, and the cancer prevalence in the study.

INTERPRETATION

ENB is very safe with good sensitivity for diagnosing malignancy in patients with PPLs. The applicability of our findings is limited because most studies were done with the superDimension navigation system and heterogeneity was high.

TRIAL REGISTRY

PROSPERO; No.: CRD42019109449; URL: https://www.crd.york.ac.uk/prospero/.

Peripheral Lung Nodule Diagnosis and Fiducial Marker Placement Using a Novel Tip-Tracked Electromagnetic Navigation Bronchoscopy System

BACKGROUND

Electromagnetic navigation (EMN) has improved bronchoscopic access to peripheral pulmonary nodules. A novel EMN system utilizing novel tip-tracked instruments for endobronchial [electromagnetic navigation bronchoscopy (ENB)] as well as transthoracic lung biopsy [electromagnetic-guided transthoracic needle aspiration (EMTTNA)] has become available. The system provides real-time feedback as well as the ability to biopsy lesions outside of the airway. These advances have the potential to improve diagnostic yield over previous EMN systems.

METHODS

We performed a retrospective review of consecutive peripheral bronchoscopy cases utilizing a novel EMN platform for biopsy and/or fiducial marker (FM) placement at a tertiary care university hospital. We analyzed factors that may influence diagnostic yield including lesion size.

RESULTS

Our study included 108 patients who underwent EMN-guided bronchoscopy between June 2015 and April 2017 for the diagnosis of peripheral lung lesions and/or the placement of FMs for stereotactic body radiotherapy. Ninety-three patients underwent biopsy utilizing ENB +/- EMTTNA. The combined diagnostic yield was 78%. EMTTNA provided a diagnosis for 5 patients in whom the ENB biopsy results were negative. Diagnostic yield by nodules <20, 20 to 30, and >30 mm in size was 30/45 (67%), 27/30 (90%), and 16/18 (89%), respectively. Sixty-five patients underwent FM placement with a total of 133 FM placed.

CONCLUSION

This novel tip-tracked EMN system incorporating both ENB and EMTTNA can guide biopsy and FM placement with a high degree of success and with a low complication rate. Multicentered prospective trials are required to develop algorithmic approaches to combine ENB and EMTTNA into a single procedure.

Electromagnetic Navigational Bronchoscopy for Peripheral Pulmonary Nodules

Electromagnetic navigational bronchoscopy is a useful addition to the array of modalities available to sample peripheral lung lesions. Its utility in diagnosing peripheral lesions has been steadily increasing since the Food and Drug Administration first approved it in 2004. The improvement can be attributed to continuous refinement in technology, increasing training and experience with the procedure, perhaps widespread availability of rapid onsite cytologic evaluation, and better patient selection. It may also be attributable to improvements of the technology and more available tools to perform biopsy of the peripheral lung.

Electromagnetic navigation bronchoscopy-guided fine needle aspiration for the diagnosis of lung lesions

Many peripheral lung lesions are beyond the reach of conventional bronchoscopes, and require percutaneous CT-guided or open surgical biopsy, which carry increased risks to the patient. Electromagnetic navigation bronchoscopy (ENB) is a relatively new technique, which uses an image guided localization system to direct steerable bronchoscopic tools to predetermined points within the bronchial tree. This technology allows improved access to peripheral lesions in particular. We investigated the sensitivity and specificity of ENB-guided fine needle aspiration (FNA) in the diagnosis of lung lesions. All ENB-guided FNAs performed at one institution were included in the study. The superDimension i-Logic System™ was used in all cases. Pathologic reports of the ENB-guided FNAs, as well as all other pulmonary sampling performed simultaneously with the FNA and within 1 year of the ENB-guided FNA were reviewed. Patients with a positive ENB-guided FNA or malignancy within the same lobe within the follow-up period were considered positive for malignancy. Patients with an atypical diagnosis but no definitive malignancy were considered negative for malignancy for statistical purposes. Ninety-one patients underwent 95 ENB-guided FNAs over a 3-year period. Thirty-five patients (38%) were positive for malignancy. ENB-guided FNA had a sensitivity of 63% for the detection of malignancy. The sensitivity for the detection of malignancy using all ENB-guided sampling methods, including FNA, bronchoscopic biopsy, and bronchial brushing was 83%. Pathologists and cytotechnologists should be aware of ENB-guided FNA as an emerging technology with a relatively high sensitivity for the diagnosis of peripheral lung lesions.

Electromagnetic navigation-guided TBNA vs conventional TBNA in the diagnosis of mediastinal lymphadenopathy

OBJECTIVES

Conventional transbronchial needle aspiration (C-TBNA) is a safe method for the diagnosis of hilar and mediastinal lymphadenopathy (MLN). However, diagnostic yield of this technique varies considerably. Electromagnetic navigation bronchoscopy (ENB) is a new technology to increase the diagnostic yield of flexible bronchoscopy for the peripheral lung lesions and MLN. The aim of this prospective study was to compare the diagnostic and sampling success of ENB-guided TBNA (ENB-TBNA) in comparison with C-TBNA while dealing with MLN.

METHODS

Consecutive patients with MLN were randomized into two groups - C-TBNA and ENB-TBNA - using a computer-based number shuffling system to avoid recruitment bias. Procedures were performed in usual fashion, published previously.

RESULTS

Ninety-four cases (M/F: 45/49) with a total of 145 stations of MLN were enrolled in the study. In 44 patients, 81 stations were sampled by ENB-TBNA, and in 50 patients 64 stations by C-TBNA. The mean size of MLN in study subjects was 17.56 ± 6.25 mm. The sampling success was significantly higher in ENB-TBNA group (82.7%) compared with C-TBNA group (51.6%) (P < 0.005). Defined by histopathological result, the diagnostic yield in ENB-TBNA was 72.8%, and 42.2% with C-TBNA (P < 0.005). For subcarinal localization, sampling or diagnostic success was higher in ENB-TBNA than that of C-TBNA (P < 0.05). Based on the size of the MLN ≤15 mm or >15 mm, the sampling success of ENB-TBNA was also significantly higher than C-TBNA in both subgroups (P < 0.005 and P < 0.005, respectively). No serious complication was observed.

CONCLUSION

In this study comparing ENB-TBNA and C-TBNA, the sampling and diagnostic success of ENB-TBNA was found to be superior while dealing with MLN, in all categories studied.

Diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules: a systematic review and meta-analysis

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) is an emerging endoscopic technique for the diagnosis of peripheral lung lesions. A thorough analysis of ENB's yield and safety is required for comparison to other sampling modalities.

OBJECTIVES

To describe ENB's yield and safety profile.

METHODS

The MEDLINE and EMBASE databases were systematically searched for studies reporting ENB's yield for peripheral lung lesions. Two independent investigators extracted data and rated each study on a scale of methodological quality. Clearly defined performance outcomes were reconstructed and meta-analyzed. Subgroup analysis and meta-regression were used to identify possible sources of study heterogeneity.

RESULTS

A total of 15 trials were included (1,033 lung nodules). A positive and definitive diagnosis was obtained after 64.9% of all ENB procedures (95% CI 59.2-70.3). Overall diagnostic accuracy was 73.9% (95% CI 68.0-79.2). Sensitivity to detect cancer was 71.1% (95% CI 64.6-76.8), with a negative predictive value of 52.1% (95% CI 43.5-60.6). Pneumothorax occurred in 3.1% of patients, requiring chest tube drainage in 1.6% of these cases. Original trials identified 6 variables associated with higher ENB yields: nodule location in the upper or middle lobes, nodule size, lower registration error, presence of a bronchus sign on CT imaging, combined use of an ultrasonic radial probe, and catheter suctioning as a sampling technique. Heterogeneity exploration revealed that studies using general anesthesia or rapid on-site cytological evaluation reported better yields.

CONCLUSIONS

ENB is effective and particularly safe. Prospective studies are needed to clarify the role of several variables conditioning the yield of this technique.

Newer modalities in the work-up of peripheral pulmonary nodules

Technological advances in recent years have translated into the availability of newer modalities to establish the cause of peripheral pulmonary nodules (PPN). Even though the verdict is still out on the ideal diagnostic modality, there is no doubt that the bronchoscope is becoming a popular tool in the armamentarium of physicians who deal with PPN. This article focuses on newer bronchoscopic modalities being studied for the work-up of PPN. The authors also summarize the value of established diagnostic modalities to provide a balanced perspective.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Multicenter experience with electromagnetic navigation bronchoscopy for the diagnosis of pulmonary nodules

BACKGROUND

Physicians are increasingly encountering lung nodules in their practice, and tissue diagnosis is often required. Conventional bronchoscopic sampling yields a range from 14% to 69% depending on the nodule size and location within the lung. We aimed to evaluate the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) in multiple centers and to determine what factors affect the yield of ENB.

METHODS

A retrospective analysis of 92 consecutive ENB procedures at 5 centers was carried out. Data were collected on patient demographics, nodule characteristics, complications, type of samples obtained, diagnosis, and follow-up studies. Variables were analyzed to determine as to which factors had an impact on the diagnostic yield with multiple logistic regression analysis.

RESULTS

Ninety-two patients underwent EMB at 5 centers between December 2008 and October 2009. The average nodule size was 2.61 cm (SD 1.42) at a distance of 1.81 cm (SD 1.32) from the pleural surface. The overall yield for ENB-guided sampling of pulmonary nodules was 65% (60/92). The ENB yield for nodules ≤2 versus >2 cm in size was significantly less after controlling for the distance from the pleura (50% vs. 76%, respectively; P=0.01). The distance from the pleura did not affect the ENB diagnostic yield after controlling for nodule size (P=0.92). The lobar location of the nodule also did not affect the diagnostic yield (P=0.59).

CONCLUSIONS

The diagnostic yield of ENB-guided sampling of pulmonary nodules is impacted by the nodule size, but not by the distance from the pleura or the lobar location.

Electromagnetic navigational bronchoscopy in the diagnosis of lung lesions

BACKGROUND

The diagnosis of pulmonary lesions that are not bronchoscopically visible is a challenging process. Electromagnetic navigation bronchoscopy (ENB) is a new technology designed to diagnose peripheral pulmonary lesions. We sought to determine whether diagnostic yield from ENB was affected by bronchus sign, lesion location, or size.

METHODS

Data were obtained retrospectively from all patients undergoing ENB at our institution since 2008. ENB was performed by 3 separate proceduralists at our institution from November 2008 until July 2011 using the superDimension/InReach system. Patient selection and modalities of specimen collection were at the discretion of the proceduralist. All procedures were performed using general anesthesia and fluoroscopy. Lesion size, location, diagnosis from ENB, and eventual diagnosis were recorded.

RESULTS

Fifty-five individuals underwent ENB between 2008 and 2011. The average lesion size was 3.0 cm and the majority of lesions were located in the upper lobes (34/55 lesions). Of the 55 patients, in 41, a diagnosis was established from ENB, a diagnostic yield of 74.5%. Thirty-six patients were eventually diagnosed with a malignancy, of whom 25 were diagnosed by ENB, yielding a sensitivity for malignancy of 69.4%. The negative predictive value for malignancy with an ENB procedure was 54.2%. There were 2 cases of postprocedure respiratory failure, but there were no cases of pneumothorax. Bronchus sign, lesion size, and location did not affect the diagnostic yield.

CONCLUSIONS

ENB shows an acceptable diagnostic yield with an excellent safety profile in the diagnosis of pulmonary lesions. The use of fluoroscopy and general anesthesia may improve the diagnostic yield.

Diagnosis of lung nodules with peripheral/radial endobronchial ultrasound-guided transbronchial biopsy

BACKGROUND

: Pulmonary nodules are frequently encountered in clinical practice, but diagnostic sensitivity of traditional bronchoscopy remains less than desirable. Transbronchial biopsy (TBBX) under fluoroscopic guidance with flexible bronchoscopy has a sensitivity of 34% for lesions <20 mm and 63% for lesions >20 mm. Navigational technologies such as electromagnetic navigation bronchoscopy have increased the yields of TBBX to approximately 73%. We examine the sensitivity and factors that may impact the diagnostic yield of a similar technology, namely, radial endobronchial ultrasound (EBUS).

METHODS

: We conducted a retrospective review of 40 consecutive patients at a single institution who underwent TBBX of lung nodules ≤3 cm using radial EBUS guidance. We evaluated patient demographics, lung function, procedural sedation, nodule size and location, presence of a radiographic airway leading into the nodule (ie, bronchus sign), distance from the pleura, and metabolic activity on positron emission tomography scan. Nonmalignant biopsy results were compared with subsequent surgical resection or establishment of nonmalignancy based on radiographic stability over time.

RESULTS

: Overall, the diagnostic yield of radial EBUS-guided bronchoscopy was 65%. Sensitivity was 71% in malignant disease and 82% in nonmalignant disease. Presence of a bronchus sign, nodule size, nodule location, distance from the pleura, and method of sedation did not have any impact on the yield of radial EBUS-guided TBBX (P≥0.21).

CONCLUSIONS

: Lesion size, distance, presence of a computerized tomography bronchus sign, or lobar location may not impact the diagnostic yield of bronchoscopic biopsy of peripheral lung nodules with radial EBUS navigation.

Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule

BACKGROUND

The detection of pulmonary nodules (PNs) is likely to increase, especially with the release of the National Lung Screen Trials. When tissue diagnosis is desired, transthoracic needle aspiration (TTNA) is recommended. Several guided-bronchoscopy technologies have been developed to improve the yield of transbronchial biopsy for PN diagnosis: electromagnetic navigation bronchoscopy (ENB), virtual bronchoscopy (VB), radial endobronchial ultrasound (R-EBUS), ultrathin bronchoscope, and guide sheath. We undertook this meta-analysis to determine the overall diagnostic yield of guided bronchoscopy using one or a combination of the modalities described here.

METHODS

We performed a MEDLINE search using “bronchoscopy” and “solitary pulmonary nodule.” Studies evaluating the diagnostic yield of ENB, VB, R-EBUS, ultrathin bronchoscope, and/or guide sheath for peripheral nodules were included. The overall diagnostic yield and yield based on size were extracted. Adverse events, if reported, were recorded. Meta-analysis techniques incorporating inverse variance weighting and a random-effects meta-analysis approach were used.

RESULTS

A total of 3,052 lesions from 39 studies were included. The pooled diagnostic yield was 70%, which is higher than the yield for traditional transbronchial biopsy. The yield increased as the lesion size increased. The pneumothorax rate was 1.5%, which is significantly smaller than that reported for TTNA.

CONCLUSION

This meta-analysis shows that the diagnostic yield of guided bronchoscopic techniques is better than that of traditional transbronchial biopsy. Although the yield remains lower than that of TTNA, the procedural risk is lower. Guided bronchoscopy may be an alternative or be complementary to TTNA for tissue sampling of PN, but further study is needed to determine its role in the evaluation of peripheral pulmonary lesions.

Mediastinal lymph node staging: from noninvasive to surgical

OBJECTIVE

The purpose of this review is to describe the current lymph node stations and lymph node staging of non-small cell lung carcinoma. Minimally invasive and invasive methods of mediastinal lymph node staging are emphasized, and the relative accuracy and limitations of each modality are described.

CONCLUSION

Lung carcinoma remains the most common cause of cancer death in the United States. Accurate staging of lung cancer is imperative for implementing the correct therapy and assessing patient prognosis.

Electromagnetic navigation bronchoscopy (ENB): Increasing diagnostic yield

OBJECTIVES

To determine factors associated with diagnostic yield of ENB.

METHODS

In 112 consecutive patients referred to our department between March 2010 and December 2010 the diagnostic work-up for solitary pulmonary lesions included a FDG-PET-CT scan, and ENB in combination with ROSE. The final diagnosis was confirmed by histopathological evaluation of specimen obtained either by ENB, or - if ENB was not diagnostic - by CT-guided fine needle aspiration or surgery.

RESULTS

Thirty-seven (33%) subjects were female, mean age was 66.7 (±1.04) years. The mean diameter of lesions was 27mm (range: 6-46mm). In 83.9% the combination of PET-CT, ENB, and ROSE established a correct diagnosis, as defined by the definite histopathological result. 15.2% (17/112) of lesions were benign, and 84.8% (95/112) were malignant. For 112 procedures we observed a steep learning curve with a diagnostic yield of 80% and 87.5% for the first 30 and last 30 procedures, respectively. The diagnostic yield in lesions ≤20mm and >20mm in diameter was 75.6% and 89.6% (p=0.06), respectively. No significant difference in diagnostic yield was seen depending on lung function, and the localization of the lesions. Two cases (1.8%) of pneumothorax were seen during and up to 24h after bronchoscopy, none of them required a chest tube.

CONCLUSION

Diagnostic yield increased with experience but was independent from the size of the lesion, the localisation in the lungs, and lung function. The diagnostic yield of ENB can be as high as for CT-guided transthoracic biopsies but carries a significantly lower complication rate.

In vitro tests of electromagnetic interference of electromagnetic navigational bronchoscopy to implantable cardioverter defibrillators

AIMS

To characterize the electromagnetic field emitted by the electromagnetic navigational bronchoscopy (ENB) superDimension(®) Bronchus system (SDBS) and to determine whether current implantable cardioverter defibrillator (ICD) systems are suitable for use in conjunction with SDBS.

METHODS AND RESULTS

The electromagnetic emission of the SDBS location board were measured using a field strength meter connected to a low-frequency (5 Hz-100 kHz) electric and magnetic field analyser; the static magnetic field was measured using a three-axis Tesla meter. A human torso simulator was used in the in vitro experiment: a polyethylene plastic box (61 cm length × 43 cm depth × 16.5 cm height) was filled with a semisolid gel and a 0.45% saline solution to provide electric conductance similar to tissue. The ICDs were immersed 1 cm into the gel and connected with a dual-coil integrated bipolar pacing/sensing/shock lead. Tip and right ventricular coil of the lead were connected to an arrhythmia simulator using low-impedance cables. The system transmits electromagnetic waves of 2.5, 3.0, and 3.5 kHz frequency. The maximum magnetic fields measured were B = 53 and 12 µT at location board plane and at ICD plane, respectively. Corresponding figures for the electric field were E = 16.6 and 4.4 V/m. None of the tested ICDs recorded any noise signal during the period in which the location board was switched-on. Stored electrogram analysis confirmed the correct detection of simulated tachyarrhythmia and therapy delivery by every tested ICD.

CONCLUSION

The results of this study demonstrated that tested ICDs are compatible with ENB performed with SDBS. They also suggest that these results may be extended to all ICDs manufactured in compliance with current EN regulations.

Electromagnetic navigation bronchoscopy performed by thoracic surgeons: one center's early success

BACKGROUND

Multiple studies by pulmonologists have demonstrated that electromagnetic navigation bronchoscopy (ENB) can, with high diagnostic yields and low complication rates, diagnose pulmonary lesions. We believe thoracic surgeons can perform this technique with excellent early results.

METHODS

A retrospective analysis was conducted of the first consecutive 104 patients undergoing diagnostic ENB by 2 thoracic surgeons between April 2008 and October 2009. Procedures utilized general anesthesia and rapid on-site examination (ROSE) of cytopathology. All pulmonary lesions were suspicious for malignancy. Patients having negative biopsies subsequently underwent additional procedures or follow-up imaging. True negative biopsies were defined as lesions removed surgically and proven benign, lesions that disappeared on subsequent imaging, and lesions demonstrating stability over a 2-year period.

RESULTS

Of 104 patients, 3 were excluded due to insufficient follow-up. The remaining 101 patients had a median lesion size of 2.8 cm. Sixty-seven (82%) of the 82 lesions that were determined malignant had a positive diagnosis upon ENB. Of the 34 lesions without a positive ENB biopsy, 19 (56%) were categorized as true negatives: 8 had benign surgical biopsies, 6 disappeared, and 5 demonstrated stability. Consequently, 86 of 101 cases had an accurate ENB biopsy for a diagnostic yield of 85%. There was insufficient evidence to demonstrate an association between lesion size and diagnostic accuracy. There were 6 pneumothoraces (5.8%).

CONCLUSIONS

It is possible for thoracic surgeons to perform ENB with early success. The high diagnostic yields in this study may be attributed to the routine utilization of ROSE and general anesthesia, which preserves computed tomographic-to-body divergence.

Evaluation and treatment of patients with non-small cell lung cancer

Lung cancer is the most common cause of cancer-related death in the United States; however, recent clinical advances may change this outcome. New data on low-dose computed tomography for lung cancer screening, and technologic advances in surgery and radiation, have improved outcomes for those with early-stage disease. Identification of driver mutations in lung cancer has led to the development of molecular targeted therapy to improve survival of subsets of patients with metastatic disease. These advances now allow for treatment of many patients with lung cancer with comorbidities or poor performance status who would have had limited options in the past.

Electromagnetic navigation bronchoscopy

In 2009, lung cancer was estimated to be the second most common form of cancer diagnosed in men, after prostate, and the second, after breast cancer, in women. It is estimated that it caused 159,390 deaths more than breast, colon and prostate cancers combined. While age-adjusted death rates for this cancer have been declining since 2000, they remain high.

Navigational bronchoscopy: overview of technology and practical considerations--new Current Procedural Terminology codes effective 2010

Navigational bronchoscopy provides a three-dimensional virtual "roadmap" that enables a physician to maneuver through multiple branches of the bronchial tree to reach targeted lesions in distal regions of the lung. It is designed to be used with a standard bronchoscope to facilitate obtaining tissue samples and for placing radiosurgical or dye markers. This article overviews this technology and the Current Procedural Terminology codes that have been created for its use.