Ultrathin bronchoscopic cryobiopsy of peripheral pulmonary lesions

Study protocol for a randomized trial comparing cryobiopsy and conventional biopsy for peripheral pulmonary lesions

BACKGROUND

The introduction of radial endobronchial ultrasound (R-EBUS) and navigation has improved the diagnostic yield of bronchoscopy for peripheral pulmonary lesions (PPLs). Cryobiopsy could further raise the yield, and the advent of single-use cryoprobes has shown promise in enhancing yields even when used alone. This multicenter randomized controlled trial aims to compare the diagnostic performance of cryobiopsy with that of conventional biopsy during bronchoscopy for PPLs.

METHODS

The study will enroll 660 patients with PPLs ≤30 mm. Eligible patients will undergo bronchoscopy with a thin bronchoscope and R-EBUS. If the target lesion is considered reachable based on R-EBUS findings, patients will be allocated equally to the conventional biopsy and cryobiopsy groups. Conventional biopsy will be performed using forceps and/or aspiration needles, whereas cryobiopsy will employ a single-use cryoprobe. The primary endpoint is to compare the histology-based diagnostic yield between the two groups. A subgroup analysis will also be conducted based on predetermined factors to explore the populations in which cryobiopsy is likely to be effective. The secondary endpoints are to evaluate differences in diagnostic value and safety characteristics between the two groups.

DISCUSSION

This will be the first study to evaluate the efficacy of cryobiopsy in diagnostic bronchoscopy for PPLs. The results of this study directly comparing cryobiopsy with conventional biopsy will elucidate differences in their diagnostic performance.

ETHICS AND DISSEMINATION

The National Cancer Center Institutional Review Board approved this study (No. 2022-123, approval date: October 24, 2022).

TRIAL REGISTRATION

The University Hospital Medical Information Network Clinical Trials Registry (UMIN000049329).

Transbronchial Needle Aspiration via Ultrathin Bronchoscope Improves Diagnostic Yield for Peripheral Lung Lesions: Randomized Sequencing Trial

BACKGROUND

Peripheral pulmonary lesions (PPLs) are frequently identified and require diagnostic sampling. Diagnostic yield of radial endobronchial ultrasound (rEBUS) guided bronchoscopic biopsies is suboptimal, despite ultrasound confirmation of navigation success. Pairing ultrathin bronchoscopy and peripheral transbronchial needle aspiration (pTBNA) may improve yield.

METHODS

We prospectively recruited consecutive patients undergoing Olympus MP190F ultrathin bronchoscopy with rEBUS-guided sampling of PPLs. Cases were randomized to pTBNA (Olympus Periview FLEX) either before or after the usual transbronchial forceps biopsy (TBLBx) and brush. Diagnostic yield from cytology or histopathology, clinical outcomes to a minimum 24 months follow-up and complications were recorded.

RESULTS

One hundred one sampled lesions were included (pTBNA first 61, pTBNA last 40). Overall diagnostic yield was 66.3%, with no significant difference between groups (64% vs. 70% P=0.528) or prespecified subgroups according to sampling order. Seventy lesions had an end diagnosis of malignancy, of which 50 were correctly diagnosed (71.4%). TBLBx (49/96, 49%) and pTBNA (48/101, 47.5%) had the highest individual positive yield. For 12 (11.9%) participants, pTBNA was the only positive sample. Lesions <20 mm and those with eccentric rEBUS image seemed to benefit most from this approach. Rapid on-site cytologic examination (ROSE) was associated with both positive procedural diagnosis (P=0.019) and pTBNA-positive samples (P=0.004). Pneumothorax occurred in 4% and moderate bleeding in 5%. Thirteen percent had an unplanned admission within 1 month of bronchoscopy.

CONCLUSION

Adding pTBNA to conventional sampling through an ultrathin bronchoscope guided by rEBUS, improved diagnostic yield (11.9% additional diagnoses). The sampling sequence did not affect the yield of pTBNA.

Peripheral pulmonary lesion: novel approaches in endoscopic guidance systems and a state-of-the-art review

Diagnosis of peripheral pulmonary lesion (PPL) is the most challenging field in bronchoscopy and interventional pulmonology, which concerns early lung cancer diagnosis. Despite novel techniques and new approaches to the periphery of the lung, almost 25% of PPLs remain undiagnosed. Bronchoscopy with guide systems, virtual and/or electromagnetic navigation, robotic bronchoscopy, and transparenchymal nodule approaches tend to provide a higher percentage of reaching the lesion, but the diagnostic yield rarely exceeds 75%, regardless of the instruments used. Further studies are needed to evaluate what the main constraints of this discrepancy are and if a combined use of these techniques and instruments can provide an increased diagnostic yield.

Pulmonary endoscopy - central to an interventional pulmonology program

INTRODUCTION

Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options.

AREAS COVERED

This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques.

EXPERT OPINION

EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Cryobiopsy versus fine-needle aspiration for shape-sensing robotic-assisted sampling of small lung nodules

INTRODUCTION

Shape-sensing Robotic-assisted Bronchoscopy (ssRAB) has emerged as a promising tool for improved performance when sampling pulmonary nodules (PPN). Previous studies suggest that the 1.1 mm cryoprobe is as effective compared to fine needle aspiration (FNA), for different lesions sizes. We aim to compare the 1.1 mm cryoprobe performance to FNA for sampling PPN < 20 mm with ssRAB.

MATERIAL AND METHODS

We conducted a retrospective cohort study from November 2022 to February 2024 of patients who underwent ssRAB with cryobiopsy for evaluation of PPN. We compared the diagnostic yield and sensitivity for malignancy of cryobiopsy and FNA for the same PPN. Descriptive statistical analysis was conducted using the McNemar's Test and Comparison of proportion. Multivariate logistic regression assessed the impact of PPN characteristics on the yield of each tool.

RESULTS

We included 256 patients, with a combined 284 procedures, and 324 nodules sampled. The median maximum and minimum nodule size was 1.6 cm (IQR 1.17-2.4) and 1.17 cm (IQR 0.86-1.7) respectively. The overall ssRAB diagnostic yield was 93.8 % and sensitivity for malignancy was 97.5 %. Cryobiopsy had a diagnostic yield of 92 % and sensitivity of 96 %, FNA had a 70.4 % and 79.29 % respectively (P < 0.001). Cryobiopsy had a significantly higher performance compared to FNA across the analyzed categories (P < 0.05), except for the sensitivity of mixed-type lesions (P = 0.11). PPN < 10 mm and ≥ 10 mm - <15 mm sampled with FNA, had lower odds of achieving a diagnosis compared to the ≥ 20 mm group (OR = 0.305 IC95%: 0.142-0.65, p < 0.001; OR = 0.497 IC95%: 0.263-0.939, p = 0.031, respectively). Complications occurred in 5.98 % (N = 17) of cases.

CONCLUSION

Cryobiopsy demonstrates a statistically higher diagnostic yield and sensitivity for malignancy compared to FNA. Remarkably, FNA showed reduced diagnostic odds in PPN < 15 mm. ssRAB with cryobiopsy could enhance PPN diagnostic yield, leading to earlier lung cancer diagnosis and improve long-term survival rates.

Bronchial branch tracing navigation in ultrathin bronchoscopy-guided radial endobronchial ultrasound for peripheral pulmonary nodule

BACKGROUND

Most malignant peripheral pulmonary lesions (PPLs) are situated in the peripheral region of the lung. Although the ultrathin bronchoscope (UTB) can access these areas, a robust navigation system is essential for precise localisation of these small peripheral PPLs. Since many UTB procedures rely on automated virtual bronchoscopic navigation (VBN), this study aims to determine the accuracy and diagnostic yield of the manual bronchial branch tracing (BBT) navigation in UTB-guided radial endobronchial ultrasound (rEBUS) procedures.

METHODS

Single-centre retrospective study of UTB-rEBUS patients with PPLs smaller than 3 cm over a two year period.

RESULTS

Our cohort consisted of 47 patients with a mean age of 61.6 (SD 9.53) years and a mean target size of 1.91 (SD 0.53) cm. Among these lesions, 46.8% were located in the 6th airway generation, and 78.7% exhibited a direct bronchus sign. Navigation success using BBT was 91.5% based on positive rEBUS identification. The index diagnostic yield was 82.9%, increasing to 91.5% at 12 months of follow-up. Malignant lesions accounted for 65.1% of cases, while 34.9% were non-malignant. The presence of a direct bronchus sign was the sole factor associated with higher navigation success and diagnostic yield. Cryobiopsy outperformed forceps biopsy in non-concentric rEBUS lesions (90.9% vs. 50.0%, p < 0.05), but not in concentric orientated lesions. One pneumothorax occurred in our cohort.

CONCLUSIONS

BBT as an exclusive navigation method for small PPLs in UTB-rEBUS procedures has proved to be safe and feasible. Combination of UTB with cryobiopsy remains efficient for eccentric and adjacently oriented rEBUS lesions.

Value of ultrathin bronchoscope in improving the endobronchial ultrasound localization rate and diagnosing peripheral pulmonary nodules by cryobiopsy

BACKGROUND

A 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel provides better accessibility to peripheral bronchi. A 4.0-mm thin bronchoscope with a larger 2.0-mm working channel facilitates the use of a guide sheath (GS), ensuring repeated sampling from the same location. The 1.1-mm ultrathin cryoprobe has a smaller diameter, overcoming the limitation of the size of biopsy instruments used with UTB. In this study, we compared the endobronchial ultrasound localization rate and diagnostic yield of peripheral lung lesions by cryobiopsy using UTB and thin bronchoscopy combined with GS.

METHODS

We retrospectively evaluated 133 patients with peripheral pulmonary lesions with a diameter less than 30 mm who underwent bronchoscopy with either thin bronchoscope or UTB from May 2019 to May 2023. A 3.0-mm UTB combined with rEBUS was used in the UTB group, whereas a 4.0-mm thin bronchoscope combined with rEBUS and GS was used for the thin bronchoscope group. A 1.1-mm ultrathin cryoprobe was used for cryobiopsy in the two groups.

RESULTS

Among the 133 patients, peripheral pulmonary nodules in 85 subjects were visualized using r-EBUS. The ultrasound localization rate was significantly higher in the UTB group than in the thin bronchoscope group (96.0% vs. 44.6%, respectively; P < 0.001). The diagnostic yield of cryobiopsy specimens from the UTB group was significantly higher compared to the thin bronchoscope group (54.0% vs. 30.1%, respectively; p = 0.006). Univariate analysis demonstrated that the cryobiopsy diagnostic yields of the UTB group were significantly higher for lesions ≤ 20 mm, benign lesions, upper lobe lesions, lesions located lateral one-third from the hilum, and lesions without bronchus sign.

CONCLUSIONS

Ultrathin bronchoscopy combined with cryobiopsy has a superior ultrasound localization rate and diagnostic yield compared to a combination of cryobiopsy and thin bronchoscopy.

Transbronchial lung cryobiopsy for peripheral pulmonary lesions. A narrative review

An increasing number of peripheral pulmonary lesions (PPLs) requiring tissue verification to establish a definite diagnosis for further individualized management are detected due to the growing adoption of lung cancer screening by chest computed tomography (CT), especially low-dose CT. However, the morphological diagnosis of PPLs remains challenging. Transbronchial lung cryobiopsy (TBLC) that can retrieve larger specimens with more preserved cellular architecture and fewer crush artifacts in comparison with conventional transbronchial forceps biopsy (TBFB), as an emerging technology for diagnosing PPLs, has been demonstrated to have the potential to resolve the clinical dilemma pertaining to currently available sampling devices (e.g., forceps, needle and brush) and become a diagnostic cornerstone for PPLs. Of note, with the introduction of the 1.1 mm cryoprobe that will be more compatible with advanced bronchoscopic navigation techniques, such as radial endobronchial ultrasound (r-EBUS), virtual bronchoscopic navigation (VBN) and electromagnetic navigation bronchoscopy (ENB), the use of TBLC is expected to gain more popularity in the diagnosis of PPLs. While much remains for exploration using the TBLC technique for diagnosing PPLs, it can be envisaged that the emergence of additional studies with larger data accrual will hopefully add to the body of evidence in this field.

Contemporary Concise Review 2023: Advances in lung cancer and interventional pulmonology

Eligibility criteria for lung cancer screening increasingly need to consider family history of lung cancer, as well as age and smoking status. Lung cancer screening will reveal a multitude of incidental findings, of variable clinical significance, and with a need for clear pathways of management. Pulmonary nodule sampling is enhanced by intra-procedural imaging and cutting-edge robotic technology. Systematic thoracic lymph node sampling has implications for treatment efficacy. Bronchoscopic ablative techniques are feasible for peripheral lung cancers. Bronchoscopic sampling continues to have a high yield for lung cancer molecular characterization. Immunotherapy indications have expanded to include early stage and resectable lung cancer.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Radial endobronchial ultrasound - guided bronchoscopy for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis of prospective trials

Background

The diagnostic yield of radial endobronchial ultrasound (r-EBUS) for the diagnosis of peripheral pulmonary lesions (PPLs) varies between studies and is affected by multiple factors. We aimed to evaluate the efficacy and safety of r-EBUS, and to explore the factors influencing the diagnostic yield of r-EBUS in patients with PPLs.

Methods

The PubMed, Web of Science, and EMBASE databases were searched to identify relevant studies that used r-EBUS for diagnosing PPLs from the date of inception to Dec 2022. Meta-analysis was conducted using Review Manager 5.4 and Stata 15.1.

Results

An analysis of 46 studies with a total of 7252 PPLs was performed. The pooled diagnostic yield of r-EBUS was 73.4 % (95 % CI: 69.9%-76.7 %), with significant heterogeneity detected among studies (I2 = 90 %, P < 0.001). Further analysis demonstrated PPLs located in the middle or lower lobe, >2 cm in size, malignant in type, solid in appearance on computerized tomography (CT), present in bronchus sign, the within probe location, and the addition of rapid on-site evaluation (ROSE) were associated with increased diagnostic yield, whereas use of a guide sheath (GS), bronchoscopy type, and a multimodality approach failed to influence the outcome. The pooled incidence rates of overall complications, pneumothorax and moderate and severe bleeding were 3.1 % (95 % CI: 2.1%-4.3 %), 0.4 % (95 % CI: 0.1%-0.7 %) and 1.1 % (95 % CI: 0.5%-2.0 %), respectively.

Conclusions

r-EBUS has an appreciable diagnostic yield and an excellent safety manifestation when used to deal with PPLs.

A case with multiple nodules and mucosal oedema of the trachea and both bronchi induced by IgG4-related disease

BACKGROUND

IgG4-related disease is a systemic fibroinflammatory disease that is mainly seen in older men, and involves multiple organs, such as the pancreas and lungs. However, 75% of patients with IgG4-related lung disease are asymptomatic (if they are symptomatic, they mainly complain of nasal congestion, rhinorrhoea, chest pain, and cough) and are incidentally diagnosed through chest computed tomograph. Although, nodules in the airway and bronchial wall thickening are criteria for diagnosis, it is important that nodules have been reported in peripheral airways in several cases and rarely in the central airway.

CASE PRESENTATION

A 74-year-old woman previously diagnosed with Mikulicz's disease presented with swelling of the eyelid margin on both sides and visual disturbances. Computed tomography revealed extensive multiple nodules and mucosal oedema of the trachea and both bronchi. On flexible bronchoscopy under local anaesthesia, extensive lesions were observed from the middle of the trachea to the carina, extending into both segmental bronchi. The nodules were continuous with the normal respiratory tract mucosa, and the surfaces were smooth with minimal neovascularisation. Due to the solid nature of the lesion, obtaining an adequate amount of specimen was challenging. Therefore, we used a 1.9 mm cryoprobe under intubation, resulting in minimal bleeding. Subsequently, the patient was diagnosed with IgG4-related lung disease.

CONCLUSIONS

The present case is very rare because of the presence of multiple nodules, severe mucosal edema of the central airway and the absence of mediastinal lymphadenopathy, ground glass nodules, and lung masses. Therefore, it is important to consider differential diagnoses. Thus, we emphasise the importance of endobronchial cryobiopsy for obtaining an adequate number of tissue specimens in such cases to establish a definitive pathological diagnosis.

Transbronchial cryobiopsy for small peripheral pulmonary lesions using endobronchial ultrasonography and an ultrathin bronchoscope

BACKGROUND

Transbronchial biopsy using an ultrathin bronchoscope (UTB) has a high diagnostic yield for peripheral pulmonary lesions (PPLs). When combined with peripheral transbronchial needle aspiration (pTBNA), it improves the diagnostic yield of "adjacent to" radial endobronchial ultrasonography (rEBUS) findings. However, pTBNA is a complicated technique, and the specimen volume is often inadequate for diagnostic and multiplex analyses. Recently, transbronchial cryobiopsy (TBCB) using a 1.1-mm cryoprobe that could be inserted into an UTB has been available. We investigated whether TBCB combined with forceps biopsy using a 1.1-mm cryoprobe with an UTB improved the diagnostic yield of "adjacent to" lesions.

METHODS

The data of 66 consecutive patients who underwent TBCB and forceps biopsy using UTB (hemostasis using two-scope method) under rEBUS for small PPLs (≤30 mm) were retrospectively analyzed. The histological diagnosis rate using TBCB and forceps biopsy, TBCB alone, or forceps biopsy alone was compared between cases where the rEBUS probe was "within" and "adjacent to" lesions.

RESULTS

The diagnosis rate using TBCB and forceps biopsy was 81.8 % for all lesions ("within" vs. "adjacent to" cases: 88.4 % vs. 69.6 %; p = 0.093). The corresponding rate using TBCB alone was 80.3 % (86.0 % vs. 69.6 %; p = 0.19), and that using forceps biopsy alone was 62.1 % (74.4 % vs. 39.1 %; p = 0.008). Bleeding leading to discontinuation of the examination occurred in four (6.1 %) patients; however, in all cases, bleeding could be controlled endoscopically.

CONCLUSION

Forceps biopsy with TBCB during ultrathin bronchoscopy for small PPLs improved the diagnostic yield when the lesions were adjacent to the rEBUS probe.

Suitability of respiratory endoscopy for sampling malignant thoracic tumors for comprehensive genomic profiling

Comprehensive genomic profiling (CGP) is implemented to detect actionable gene aberrations and design matched therapies. Although malignant thoracic tumors are commonly detected through respiratory endoscopy, it is questionable whether the small specimens obtained thereof are sufficient for CGP. Therefore, this study aimed to investigate the suitability of respiratory endoscopy for sampling primary and metastatic thoracic tumors for CGP. Patients whose specimens were collected through respiratory endoscopy and assessed by pathologists to determine their suitability for CGP at our institution between June 2019 and May 2022 were reviewed retrospectively. The suitability of each procedure as a sampling technique for CGP and, in the cases actually analyzed, the distribution of the detected gene aberration were assessed. In total, 122 patients were eligible for analysis; the median age was 61 (range, 29-86) years, and 71 (58.2%) patients were male. Primary intrathoracic tumors were found in 91 (74.6%) cases, including 84 (68.9%) primary lung cancers; the remaining thoracic metastases of extrathoracic origin included various types. The suitability rates of specimens obtained using conventional bronchoscopy with and without cryobiopsy, endobronchial ultrasound-guided transbronchial needle aspiration, and medical thoracoscopy were 82.8% (24/29), 70.4% (19/27), 72.9% (35/48), and 100% (18/18), respectively. Of the 96 cases judged suitable, 83 were subjected to CGP, and all but one were successfully analyzed. Finally, 47 (56.6%) patients had at least one actionable gene aberration and eight (9.6%) were treated with the corresponding targeted therapies. In conclusion, specimens obtained through respiratory endoscopy are suitable for CGP; medical thoracoscopy and cryobiopsy in conventional bronchoscopy are particularly useful.

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.

Efficacy of combined transbronchial lung cryobiopsy and conventional forceps biopsy for lung malignancies: a prospective cohort study

There are few prospective reports of transbronchial lung cryobiopsy (TBLC) for malignant tumors in combination with forceps biopsy. We investigated the clinical parameters in which TBLC is superior to forceps biopsy. This is a prospective cohort study to analyse the efficacy of TBLC for suspected malignancy. TBLC was performed after brushing cytology and forceps biopsy, and the diagnostic yield for TBLC, brushing cytology, and forceps biopsy were examined. Adverse events were defined as those requiring additional procedures. Next-generation sequencing (NGS) analysis was performed in each case of non-small cell lung cancer. Of the 100 patients, malignancy was confirmed in 94 cases. The diagnostic yield for TBLC/forceps biopsy/brushing cytology was 86/81/82% respectively, while the diagnostic yield for all procedures combined was 94%. There was no significant difference in the diagnostic yield between TBLC and forceps biopsy. When comparing the biopsy site, the diagnostic yield for TBLC at the lower lobe was significantly higher than forceps biopsy (P < 0.01). Endobronchial ultrasonography imaging using a guide-sheath did not significantly differ in the diagnostic yield of TBLC. The success rate of NGS for TBLC specimens was 100% (26 cases). Adverse events included two cases of severe bleeding. TBLC of peripheral lesions may improve the diagnostic yield when combined with forceps biopsy and brushing cytology. The diagnostic yield of TBLC was higher at the lower lobes. Furthermore, TBLC provided sufficient specimen quality for NGS.