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Abdelghani R, Omballi M, Abia-Trujillo D, Casillas E, Villalobos R, Badar F, Bansal S, Kheir F. Imaging modalities during navigational bronchoscopy. Expert Rev Respir Med 2024:1-14. [PMID: 38794918 DOI: 10.1080/17476348.2024.2359601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 05/21/2024] [Indexed: 05/26/2024]
Abstract
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.
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Affiliation(s)
- Ramsy Abdelghani
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, LA, USA
| | - Mohamed Omballi
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Casillas
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Regina Villalobos
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faraz Badar
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
| | - Sandeep Bansal
- The Lung Center, Penn Highlands Healthcare, DuBois, PA, USA
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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Zhang J, Chen E, Xu S, Xu L, Hu H, Dong L, Ying K. Virtual bronchoscopic navigation with intraoperative cone-beam CT for the diagnosis of peripheral pulmonary nodules. BMC Pulm Med 2024; 24:146. [PMID: 38509516 PMCID: PMC10956201 DOI: 10.1186/s12890-024-02930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Transbronchial biopsy is a safe manner with fewer complications than percutaneous transthoracic needle biopsy; however, the current diagnostic yield is still necessitating further improvement. We aimed to evaluate the diagnostic yield of using virtual bronchoscopic navigation (VBN) and cone-beam CT (CBCT) for transbronchial biopsy and to investigate the factors that affected the diagnostic sensitivity. METHODS We retrospectively investigated 255 patients who underwent VBN-CBCT-guided transbronchial biopsy at our two centers from May 2021 to April 2022. A total of 228 patients with final diagnoses were studied. Patient characteristics including lesion size, lesion location, presence of bronchus sign, lesion type and imaging tool used were collected and analyzed. Diagnostic yield was reported overall and in groups using different imaging tools. RESULTS The median size of lesion was 21 mm (range of 15.5-29 mm) with 46.1% less than 2 cm in diameter. Bronchus sign was present in 87.7% of the patients. The overall diagnostic yield was 82.1%, and sensitivity for malignancy was 66.3%. Patients with lesion > 2 cm or with bronchus sign were shown to have a significantly higher diagnostic yield. Four patients had bleeding and no pneumothorax occurred. CONCLUSION Guided bronchoscopy with VBN and CBCT was an effective diagnostic method and was associated with a high diagnostic yield in a safe manner. In addition, the multivariant analysis suggested that lesion size and presence of bronchus sign could be a predictive factor for successful bronchoscopic diagnosis.
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Affiliation(s)
- Jisong Zhang
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Enguo Chen
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Shan Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Li Xu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Huihui Hu
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Liangliang Dong
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China
| | - Kejing Ying
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Disease, Sir Run Run Shaw hospital of Zhejiang University, 310016, Hangzhou, China.
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3
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Xu D, Xie F, Zhang J, Chen H, Chen Z, Guan Z, Hou G, Ji C, Li H, Li M, Li W, Li X, Li Y, Lian H, Liao J, Liu D, Luo Z, Ouyang H, Shen Y, Shi Y, Tang C, Wan N, Wang T, Wang H, Wang H, Wang J, Wu X, Xia Y, Xiao K, Xu W, Xu F, Yang H, Yang J, Ye T, Ye X, Yu P, Zhang N, Zhang P, Zhang Q, Zhao Q, Zheng X, Zou J, Chen E, Sun J. Chinese expert consensus on cone-beam CT-guided diagnosis, localization and treatment for pulmonary nodules. Thorac Cancer 2024; 15:582-597. [PMID: 38337087 PMCID: PMC10912555 DOI: 10.1111/1759-7714.15222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 02/12/2024] Open
Abstract
Cone-beam computed tomography (CBCT) system can provide real-time 3D images and fluoroscopy images of the region of interest during the operation. Some systems can even offer augmented fluoroscopy and puncture guidance. The use of CBCT for interventional pulmonary procedures has grown significantly in recent years, and numerous clinical studies have confirmed the technology's efficacy and safety in the diagnosis, localization, and treatment of pulmonary nodules. In order to optimize and standardize the technical specifications of CBCT and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Interventional Pulmonology of China Association for Promotion of Health Science and Technology.
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Affiliation(s)
- Dongyang Xu
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Jisong Zhang
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory DiseaseSir Run Run Shaw Hospital of Zhejiang UniversityHangzhouChina
| | - Hong Chen
- Department of Pulmonary and Critical Care MedicineSecond Affiliated Hospital of Harbin Medical UniversityHarbinChina
| | - Zhongbo Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Medical SchoolNingbo UniversityNingboChina
| | - Zhenbiao Guan
- Department of Respiration, Changhai HospitalNaval Medical UniversityShanghaiChina
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, China‐Japan Friendship HospitalBeijingChina
| | - Cheng Ji
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Haitao Li
- Department of Respiratory and Critical Care MedicineThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Manxiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Wei Li
- Department of Respiratory DiseaseThe First Affiliated Hospital of Bengbu Medical CollegeBengbuChina
| | - Xuan Li
- Department of Respiratory Medicine, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Yishi Li
- Dept of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hairong Lian
- Department of Respiratory MedicineAffiliated Hospital of Jiangnan UniversityWuxiChina
| | - Jiangrong Liao
- Department of Respiratory MedicineGuizhou Aerospace HospitalZunyiChina
| | - Dan Liu
- Department of Respiratory and Critical Care MedicineWest China Hospital of Sichuan UniversityChengduChina
| | - Zhuang Luo
- Department of Respiratory and Critical Care MedicineFirst Affiliated Hospital of Kunming Medical UniversityKunmingChina
| | - Haifeng Ouyang
- Department of Respiratory DiseasesXi'an International Medical CenterXi'anChina
| | - Yongchun Shen
- Department of Respiratory and Critical Care MedicineWest China Hospital of Sichuan UniversityChengduChina
| | - Yiwei Shi
- Department of Respiratory and Critical Care MedicineShanxi Medical University Affiliated First HospitalTaiyuanChina
| | - Chunli Tang
- China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory DiseaseThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Nansheng Wan
- Department of Respiratory and Critical Care MedicineTianjin Medical University General HospitalTianjinChina
| | - Tao Wang
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Hong Wang
- Department of Respiratory MedicineLanzhou University Second HospitalLanzhouChina
| | - Huaqi Wang
- Department of Respiratory MedicineThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Juan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xuemei Wu
- Department of Respiratory CentreThe Second Affiliated Hospital of Xiamen Medical CollegeXiamenChina
| | - Yang Xia
- Department of Respiratory and Critical Care MedicineSecond Affiliated Hospital of Zhejiang University School of MedicineHangzhouChina
| | - Kui Xiao
- Department of Respiratory Medicine, The Second Xiangya HospitalCentral South UniversityChangshaChina
| | - Wujian Xu
- Department of Respiratory and Critical Care Medicine, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Fei Xu
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Huizhen Yang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou UniversityZhengzhouChina
| | - Junyong Yang
- Department of Respiratory MedicineXinjiang Chest HospitalWulumuqiChina
| | - Taosheng Ye
- Department of TuberculosisThe Third People's Hospital of ShenzhenShenzhenChina
| | - Xianwei Ye
- Department of Pulmonary and Critical Care MedicineGuizhou Provincial People's HospitalGuiyangChina
| | - Pengfei Yu
- Department of Respiratory and Critical Care Medicine, Yantai Yuhuangding HospitalAffiliated with the Medical College of QingdaoYantaiChina
| | - Nan Zhang
- Department of Respiratory Medicine, Emergency General HospitalBeijingChina
| | - Peng Zhang
- Pulmonary Intervention DepartmentAnhui Chest HospitalHefeiChina
| | - Quncheng Zhang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou UniversityZhengzhouChina
| | - Qi Zhao
- Department of Respiratory Medicine, Nanjing Drum Tower HospitalNanjing University Medical SchoolNanjingChina
| | - Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
| | - Jun Zou
- Department of Respiratory and Critical Care Medicine, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Enguo Chen
- Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory DiseaseSir Run Run Shaw Hospital of Zhejiang UniversityHangzhouChina
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Respiratory and Critical Care Medicine, Shanghai Chest HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai Engineering Research Center of Respiratory EndoscopyShanghaiChina
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Saad F, Frysch R, Saalfeld S, Kellnberger S, Schulz J, Fahrig R, Bhadra K, Nürnberger A, Rose G. Deformable 3D/3D CT-to-digital-tomosynthesis image registration in image-guided bronchoscopy interventions. Comput Biol Med 2024; 171:108199. [PMID: 38394801 DOI: 10.1016/j.compbiomed.2024.108199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/30/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024]
Abstract
Traditional navigational bronchoscopy procedures rely on preprocedural computed tomography (CT) and intraoperative chest radiography and cone-beam CT (CBCT) to biopsy peripheral lung lesions. This navigational approach is challenging due to the projective nature of radiography, and the high radiation dose, long imaging time, and large footprints of CBCT. Digital tomosynthesis (DTS) is considered an attractive alternative combining the advantages of radiography and CBCT. Only the depth resolution cannot match a full CBCT image due to the limited angle acquisition. To address this issue, preoperative CT is a good auxiliary in guiding bronchoscopy interventions. Nevertheless, CT-to-body divergence caused by anatomic changes and respiratory motion, hinders the effective use of CT imaging. To mitigate CT-to-body divergence, we propose a novel deformable 3D/3D CT-to-DTS registration algorithm employing a multistage, multiresolution approach and using affine and elastic B-spline transformation models with bone and lung mask images. A multiresolution strategy with a Gaussian image pyramid and a multigrid strategy within the B-spline model are applied. The normalized correlation coefficient is included in the cost function for the affine model and a multimetric weighted cost function is used for the B-spline model, with weights determined heuristically. Tested on simulated and real patient bronchoscopy data, the algorithm yields promising results. Assessed qualitatively by visual inspection and quantitatively by computing the Dice coefficient (DC) and the average symmetric surface distance (ASSD), the algorithm achieves mean DC of 0.82±0.05 and 0.74±0.05, and mean ASSD of 0.65±0.29mm and 0.93±0.43mm for simulated and real data, respectively. This algorithm lays the groundwork for CT-aided intraoperative DTS imaging in image-guided bronchoscopy interventions with future studies focusing on automated metric weight setting.
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Affiliation(s)
- Fatima Saad
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany.
| | - Robert Frysch
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany
| | - Sylvia Saalfeld
- Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany; Department of Simulation and Graphics, Otto-von-Guericke University, Magdeburg, Germany
| | | | - Jessica Schulz
- Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany; Siemens Healthcare GmbH, Forchheim, Germany
| | | | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, USA
| | - Andreas Nürnberger
- Data and Knowledge Engineering Group, Faculty of Computer Science, Otto-von-Guericke University, Magdeburg, Germany
| | - Georg Rose
- Institute for Medical Engineering, Otto-von-Guericke University, Magdeburg, Germany; Forschungscampus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany
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5
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Jain A, Sarkar A, Husnain SMN, Adkinson BC, Sadoughi A, Sarkar A. Digital Tomosynthesis: Review of Current Literature and Its Impact on Diagnostic Bronchoscopy. Diagnostics (Basel) 2023; 13:2580. [PMID: 37568943 PMCID: PMC10417238 DOI: 10.3390/diagnostics13152580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
Bronchoscopy has garnered increased popularity in the biopsy of peripheral lung lesions. The development of navigational guided bronchoscopy systems along with radial endobronchial ultrasound (REBUS) allows clinicians to access and sample peripheral lesions. The development of robotic bronchoscopy improved localization of targets and diagnostic accuracy. Despite such technological advancements, published diagnostic yield remains lower compared to computer tomography (CT)-guided biopsy. The discordance between the real-time location of peripheral lesions and anticipated location from preplanned navigation software is often cited as the main variable impacting accurate biopsies. The utilization of cone beam CT (CBCT) with navigation-based bronchoscopy has been shown to assist with localizing targets in real-time and improving biopsy success. The resources, costs, and radiation associated with CBCT remains a hindrance in its wider adoption. Recently, digital tomosynthesis (DT) platforms have been developed as an alternative for real-time imaging guidance in peripheral lung lesions. In North America, there are several commercial platforms with distinct features and adaptation of DT. Early studies show the potential improvement in peripheral lesion sampling with DT. Despite the results of early observational studies, the true impact of DT-based imaging devices for peripheral lesion sampling cannot be determined without further prospective randomized trials and meta-analyses.
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Affiliation(s)
- Anant Jain
- Department of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (S.M.N.H.)
| | - Adrish Sarkar
- Department of Radiology, Nassau University Medical Center, East Meadow, NY 11554, USA;
| | - Shaikh Muhammad Noor Husnain
- Department of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (S.M.N.H.)
| | - Brian Cody Adkinson
- Department of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, Jackson Memorial Hospital, University of Miami, Miami, FL 33136, USA;
| | - Ali Sadoughi
- Department of Pulmonary Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA;
| | - Abhishek Sarkar
- Department of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (S.M.N.H.)
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Zuccatosta L, Gonnelli F, Gasparini G, Duro A, Barbisan F, Goteri G, Veronesi G, Trisolini R, Gasparini S. Possible Use of Linear Echobronchoscope for Diagnosis of Peripheral Pulmonary Nodules. Diagnostics (Basel) 2023; 13:2393. [PMID: 37510137 PMCID: PMC10378167 DOI: 10.3390/diagnostics13142393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 07/30/2023] Open
Abstract
Echobronchoscope-guided transbronchial needle aspiration (EBUS-TBNA) is mainly used as the transbronchial approach to hilar/mediastinal lymph nodes or lesions, for diagnostic or staging purposes. Moreover, the role of linear EBUS-TBNA as a diagnostic tool for central intrapulmonary lesions adjacent to the trachea or the major bronchi is also well established. However, since the tip of the ultrasound probe at the distal end of the echobronchoscope is very thin, it can be wedged through smaller peripheral bronchi, reaching the distal parenchyma and allowing for peripheral pulmonary lesion sampling. The main aim of this retrospective study was to evaluate the diagnostic yield and the safety of EBUS-TBNA in the diagnosis of pulmonary peripheral nodules. The database of the Interventional Pulmonology Unit of Azienda Ospedaliero-Universitaria delle Marche (Ancona, Italy) was evaluated to identify peripheral pulmonary nodules approached by EBUS-TBNA. Thirty patients with a single peripheral pulmonary nodule located peripherally to the subsegmental bronchi of the lower lobes and adjacent to a small bronchus greater than 3 mm in diameter were included in this study. The nodule was visible using endoscopic ultrasound in 28 patients and the diagnosis was obtained via EBUS-TBNA in 26 cases (12 adenocarcinoma, 5 typical carcinoid tumors, 4 hamartoma and 5 metastatic lesions). The diagnostic yield was 86.6% for all 30 patients and 92.8% if only the 28 patients in which the lesion was visualized via echobronchoscopy were considered. No relevant adverse events were observed. We conclude that EBUS-TBNA may be an effective and safe option to sample pulmonary peripheral nodules in selected patients with lower lobe peripheral pulmonary lesions adjacent to small bronchi greater than 3 mm in diameter and reachable with the EBUS-TBNA probe.
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Affiliation(s)
- Lina Zuccatosta
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Francesca Gonnelli
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Gianmarco Gasparini
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region, 60126 Ancona, Italy
| | - Arianna Duro
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region, 60126 Ancona, Italy
| | - Francesca Barbisan
- Pathological Anatomy Institute, Polytechnic University of Marche Region, 60126 Ancona, Italy
| | - Gaia Goteri
- Pathological Anatomy Institute, Polytechnic University of Marche Region, 60126 Ancona, Italy
| | - Giulia Veronesi
- School of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Department of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rocco Trisolini
- Interventional Pulmonology Unit, Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy
| | - Stefano Gasparini
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Nadig TR, Thomas N, Nietert PJ, Lozier J, Tanner NT, Wang Memoli JS, Pastis NJ, Silvestri GA. Guided Bronchoscopy for the Evaluation of Pulmonary Lesions: An Updated Meta-analysis. Chest 2023; 163:1589-1598. [PMID: 36640994 PMCID: PMC10925546 DOI: 10.1016/j.chest.2022.12.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Tejaswi R Nadig
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC
| | - Nina Thomas
- Division of Pulmonary Disease & Critical Care, University of Colorado, Aurora, CO
| | - Paul J Nietert
- Department of Public Health Sciences, MUSC, Charleston, SC
| | - Jessica Lozier
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC
| | - Nichole T Tanner
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC; Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital, Charleston, SC
| | - Jessica S Wang Memoli
- Division of Pulmonary, Critical Care and Respiratory Services, Medstar Washington Hospital Center, Washington, DC
| | - Nicholas J Pastis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Gerard A Silvestri
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, MUSC, Charleston, SC.
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8
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Kops SEP, Heus P, Korevaar DA, Damen JAA, Idema DL, Verhoeven RLJ, Annema JT, Hooft L, van der Heijden EHFM. Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis. Lung Cancer 2023; 180:107196. [PMID: 37130440 DOI: 10.1016/j.lungcan.2023.107196] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Navigation bronchoscopy has seen rapid development in the past decade in terms of new navigation techniques and multi-modality approaches utilizing different techniques and tools. This systematic review analyses the diagnostic yield and safety of navigation bronchoscopy for the diagnosis of peripheral pulmonary nodules suspected of lung cancer. METHODS An extensive search was performed in Embase, Medline and Cochrane CENTRAL in May 2022. Eligible studies used cone-beam CT-guided navigation (CBCT), electromagnetic navigation (EMN), robotic navigation (RB) or virtual bronchoscopy (VB) as the primary navigation technique. Primary outcomes were diagnostic yield and adverse events. Quality of studies was assessed using QUADAS-2. Random effects meta-analysis was performed, with subgroup analyses for different navigation techniques, newer versus older techniques, nodule size, publication year, and strictness of diagnostic yield definition. Explorative analyses of subgroups reported by studies was performed for nodule size and bronchus sign. RESULTS A total of 95 studies (n = 10,381 patients; n = 10,682 nodules) were included. The majority (n = 63; 66.3%) had high risk of bias or applicability concerns in at least one QUADAS-2 domain. Summary diagnostic yield was 70.9% (95%-CI 68.4%-73.2%). Overall pneumothorax rate was 2.5%. Newer navigation techniques using advanced imaging and/or robotics(CBCT, RB, tomosynthesis guided EMN; n = 24 studies) had a statistically significant higher diagnostic yield compared to longer established techniques (EMN, VB; n = 82 studies): 77.5% (95%-CI 74.7%-80.1%) vs 68.8% (95%-CI 65.9%-71.6%) (p < 0.001).Explorative subgroup analyses showed that larger nodule size and bronchus sign presence were associated with a statistically significant higher diagnostic yield. Other subgroup analyses showed no significant differences. CONCLUSION Navigation bronchoscopy is a safe procedure, with the potential for high diagnostic yield, in particular using newer techniques such as RB, CBCT and tomosynthesis-guided EMN. Studies showed a large amount of heterogeneity, making comparisons difficult. Standardized definitions for outcomes with relevant clinical context will improve future comparability.
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Affiliation(s)
- Stephan E P Kops
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Pauline Heus
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Johanna A A Damen
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Demy L Idema
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roel L J Verhoeven
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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9
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Diagnosis of Organizing Pneumonia with an Ultrathin Bronchoscope and Cone-Beam CT: A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12112813. [PMID: 36428874 PMCID: PMC9689355 DOI: 10.3390/diagnostics12112813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022] Open
Abstract
Organizing pneumonia (OP) is a pulmonary disease histopathologically characterized by plugs of loose connective tissue in distal airways. The clinical and radiological presentations are not specific and they usually require a biopsy confirmation. This paper presents the case of a patient with a pulmonary opacity sampled with a combined technique of ultrathin bronchoscopy and cone-beam CT. A 64-year-old female, a former smoker, was admitted to the hospital of Reggio Emilia (Italy) for exertional dyspnea and a dry cough without a fever. The history of the patient included primary Sjögren Syndrome interstitial lung disease (pSS-ILD) characterized by a non-specific interstitial pneumonia (NSIP) radiological pattern; this condition was successfully treated up to 18 months before the new admission. The CT scan showed the appearance of a right lower lobe pulmonary opacity of an uncertain origin that required a histological exam for the diagnosis. The lung lesion was difficult to reach with traditional bronchoscopy and a percutaneous approach was excluded. Thus, cone-beam CT, augmented fluoroscopy and ultrathin bronchoscopy were chosen to collect a tissue sample. The histopathological exam was suggestive of OP, a condition occurring in 4-11% of primary Sjögren Syndrome cases. This case showed that, in the correct clinical and radiological context, even biopsies taken with small forceps can lead to a diagnosis of OP. Moreover, it underlined that the combination of multiple advanced technologies in the same procedure can help to reach difficult target lesions, providing proper samples for a histological diagnosis.
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10
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Giri M, Dai H, Puri A, Liao J, Guo S. Advancements in navigational bronchoscopy for peripheral pulmonary lesions: A review with special focus on virtual bronchoscopic navigation. Front Med (Lausanne) 2022; 9:989184. [PMID: 36300190 PMCID: PMC9588954 DOI: 10.3389/fmed.2022.989184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Lung cancer is often diagnosed at an advanced stage and is associated with significant morbidity and mortality. Low-dose computed tomography for lung cancer screening has increased the incidence of peripheral pulmonary lesions. Surveillance and early detection of these lesions at risk of developing cancer are critical for improving patient survival. Because these lesions are usually distal to the lobar and segmental bronchi, they are not directly visible with standard flexible bronchoscopes resulting in low diagnostic yield for small lesions <2 cm. The past 30 years have seen several paradigm shifts in diagnostic bronchoscopy. Recent technological advances in navigation bronchoscopy combined with other modalities have enabled sampling lesions beyond central airways. However, smaller peripheral lesions remain challenging for bronchoscopic biopsy. This review provides an overview of recent advances in interventional bronchoscopy in the screening, diagnosis, and treatment of peripheral pulmonary lesions, with a particular focus on virtual bronchoscopic navigation.
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Affiliation(s)
- Mohan Giri
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyun Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Anju Puri
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiaxin Liao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Shuliang Guo
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11
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Kops SEP, Verhoeven RLJ, Vermeulen RJ, Rovers MM, van der Heijden EHFM, Govers TM. Cone beam CT-guided navigation bronchoscopy: a cost-effective alternative to CT-guided transthoracic biopsy for diagnosis of peripheral pulmonary nodules. BMJ Open Respir Res 2022. [PMCID: PMC9445795 DOI: 10.1136/bmjresp-2022-001280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
ObjectivesTo determine if cone beam CT-guided navigation bronchoscopy (CBCT-NB) is a cost-effective diagnostic procedure in patients with a pulmonary nodule (PN) with an intermediate risk for lung cancer.Materials and methodsTwo decision analytical models were developed to compare the long-term costs, survival and quality of life. In the first model, CBCT-NB was compared with CT-guided transthoracic needle biopsy (TTNB) in TTNB eligible patients. In the second model, CBCT-NB was compared with direct treatment (without pathology proven lung cancer) in patients for whom TTNB is not suitable. Input data were gathered in-house, from literature and expert opinion. Effects were expressed in quality-adjusted life years (QALYs). Sensitivity analyses were used to assess uncertainty.ResultsCBCT-NB can be cost-effective in TTNB eligible patients with an incremental cost-effectiveness ratio of €18 416 in an expert setting. The probabilistic sensitivity analysis showed that in 69% and 90% of iterations CBCT-NB remained cost-effective assuming a willingness to pay (WTP) of €20 000 and €80 000 per QALY. CBCT-NB dominated in the treatment strategy in which TTNB is not suitable. The probabilistic sensitivity analysis showed that in 95% of iterations CBCT-NB remained the dominant strategy, and CBCT-NB remained cost-effective in 100% of iterations assuming a WTP limit of €20 000. In the comparison between CBCT NB and TTNB, the deterministic sensitivity analysis showed that the diagnostic properties and costs of both procedures have a large impact on the outcome.ConclusionsCBCT-NB seems a cost-effective procedure when compared with TTNB and when compared with a direct treatment strategy in patients with an intermediate risk PN.
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Affiliation(s)
- Stephan E P Kops
- Department of Pulmonary Diseases, Radboudumc, Nijmegen, The Netherlands
| | | | - Robin J Vermeulen
- Department of Medical Imaging, Radboudumc, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Medical Imaging, Radboudumc, Nijmegen, The Netherlands
| | | | - Tim M Govers
- Department of Medical Imaging, Radboudumc, Nijmegen, The Netherlands
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12
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Podder S, Chaudry S, Singh H, Jondall EM, Kurman JS, Benn BS. Efficacy and Safety of Cone-Beam CT Augmented Electromagnetic Navigation Guided Bronchoscopic Biopsies of Indeterminate Pulmonary Nodules. Tomography 2022; 8:2049-2058. [PMID: 36006070 PMCID: PMC9412509 DOI: 10.3390/tomography8040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Bronchoscopic biopsy results for indeterminate pulmonary nodules remain suboptimal. Electromagnetic navigation bronchoscopy (ENB) coupled with cone beam computed tomography (CBCT) for confirmation has the potential to improve diagnostic yield. We present our experience using this multimodal approach to biopsy 17 indeterminate nodules in 14 consecutive patients from April to August 2021. Demographic information, nodule characteristics, and biopsy results were recorded. Procedures were performed in a hybrid operating room equipped with a Siemens Artis Q bi-plane CBCT (Siemens, Munich, Germany). After ENB using the superDimension version 7.1 (Medtronic, Plymouth, MN, USA) to target the lesion, radial endobronchial ultrasound was used as secondary confirmation. Next, transbronchial needle aspiration was performed prior to CBCT to evaluate placement of the biopsy tool in the lesion. The average nodule size was 21.7+/−15 mm with 59% (10/17) < 2 cm in all dimensions and 35% (6/17) showing a radiographic bronchus sign. The diagnostic yield of CBCT-guided ENB was 76% (13/17). No immediate periprocedural or postprocedural complications were identified. Our experience with CBCT-guided ENB further supports the comparable efficacy and safety of this procedure compared to other mature biopsy modalities. Studies designed to optimize the lung nodule biopsy process and to determine the contributions from different procedural aspects are warranted.
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13
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Bhadra K, Setser RM, Condra W, Pritchett MA. Lung Navigation Ventilation Protocol to Optimize Biopsy of Peripheral Lung Lesions. J Bronchology Interv Pulmonol 2022; 29:7-17. [PMID: 33734150 DOI: 10.1097/lbr.0000000000000756] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Computed tomography-to-body divergence caused by respiratory motion, atelectasis, diaphragmatic motion and other factors is an obstacle to peripheral lung biopsies. We examined a conventional ventilation strategy versus a lung navigation ventilation protocol (LNVP) optimized for intraprocedural 3-dimensional image acquisition and bronchoscopic biopsy of peripheral lung nodules. METHODS A retrospective, single center study was conducted in consecutive subjects with peripheral lung lesions measuring <30 mm. Effects of ventilation strategies including atelectasis and tool-in-lesion confirmation were assessed using cone beam computed tomography images. Diagnostic yield was also evaluated. Complications were assessed through 7 days. RESULTS Fifty subjects were included (25 per group) with 27 nodules in the conventional group and 25 nodules in the LNVP group. Atelectasis was assessed by 2 blinded readers: [reader 1 (R1) and reader 2 (R2)]. Atelectasis was more prevalent in the conventional ventilation group, both for dependent atelectasis (R1: 64% and R2: 68% vs. R1: 36% and R2: 16%, P=0.00014) and sublobar/lobar atelectasis (R1: 48% and R2: 56% vs. R1: 20% and R2: 32%, P=0.01). Similarly, the target lesion was obscured due to atelectasis more often in the conventional ventilation group (R1: 36% and R2: 36% vs. R1: 4% and R2: 8%, P=0.01). Diagnostic yield was 70% for conventional ventilation and 92% for LNVP (P=0.08). CONCLUSION LNVP demonstrated markedly reduced dependent and sublobar/lobar atelectasis and lesions either partially or completely obscured by atelectasis compared with conventional ventilation. Future prospective studies are necessary to understand the impact of protocolized ventilation strategies for bronchoscopic biopsy of peripheral lung lesions.
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Affiliation(s)
- Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN
| | | | - William Condra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN
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14
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Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Improves the Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Biopsy for Peripheral Pulmonary Lesions. Diagnostics (Basel) 2021; 12:diagnostics12010041. [PMID: 35054208 PMCID: PMC8774719 DOI: 10.3390/diagnostics12010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of peripheral pulmonary lesions (PPLs), but the diagnostic yield is not adequate. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) can be utilized to assess the location of PPLs and biopsy devices, and has the potential to improve the diagnostic accuracy of bronchoscopic techniques. The purpose of this study was to verify the contribution of CBCT-AF to EBUS-TBB. Methods: Patients who underwent EBUS-TBB for diagnosis of PPLs were enrolled. The navigation success rate and diagnostic yield were used to evaluate the effectiveness of CBCT-AF in EBUS-TBB. Results: In this study, 236 patients who underwent EBUS-TBB for PPL diagnosis were enrolled. One hundred fifteen patients were in CBCT-AF group and 121 were in non-AF group. The navigation success rate was significantly higher in the CBCT-AF group (96.5% vs. 86.8%, p = 0.006). The diagnostic yield was even better in the CBCT-AF group when the target lesion was small in size (68.8% vs. 0%, p = 0.026 for lesions ≤10 mm and 77.5% vs. 46.4%, p = 0.016 for lesions 10–20 mm, respectively). The diagnostic yield of the two study groups became similar when the procedures with a failure of navigation were excluded. The procedure-related complication rate was similar between the two study groups. Conclusion: CBCT-AF is safe, and effectively enhances the navigation success rate, thereby increasing the diagnostic yield of EBUS-TBB for PPLs.
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15
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Piro R, Fontana M, Casalini E, Taddei S, Bertolini M, Iori M, Facciolongo N. Cone beam CT augmented fluoroscopy allows safe and efficient diagnosis of a difficult lung nodule. BMC Pulm Med 2021; 21:327. [PMID: 34670551 PMCID: PMC8527755 DOI: 10.1186/s12890-021-01697-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Background Detection of small peripheral lung nodules is constantly increasing with the development of low dose computed tomography lung cancer screening programs. A tissue diagnosis is often required to confirm malignity, with endobronchial biopsies being associated with a lower pneumothorax rate than percutaneous approaches. Endoscopic diagnosis of peripheral small size lung nodules is however often challenging using traditional bronchoscopy and endobronchial ultrasound alone. New virtual bronchoscopic navigation techniques such as electromagnetic navigational bronchoscopy (ENB) have developed to improve peripheral navigation, with diagnostic yield however remaining in the 30–50% range for small lesions. Recent studies have shown the benefits of combining Cone beam computed tomography (CBCT) with ENB to improve diagnostic yield to up to 83%. The use of ENB however remains limited by disposable cost, bronchus sign dependency and inaccuracies due to CT to body divergence. Case presentation This case report highlights the feasibility and usefulness of CBCT-guided bronchoscopy for the sampling of lung nodules difficult to reach through traditional bronchoscopy because of nodule size and peripheral position. Procedure was scheduled in a mobile robotic hybrid operating room with patient under general anaesthesia. CBCT acquisition was performed to localize the target lesion and plan the best path to reach it into bronchial tree. A dedicated software was used to segment the lesion and the bronchial path which 3D outlines were automatically fused in real time on the fluoroscopic images to augment live guidance. Navigation to the lesion was guided with bronchoscopy and augmented fluoroscopy alone. Before the sampling, CBCT imaging was repeated to confirm the proper position of the instrument into the lesion. Four transbronchial needle aspirations (TBNA) were performed and the tissue analysis showed a primary lung adenocarcinoma. Conclusions CBCT and augmented fluoroscopy technique is a safe and effective and has potential to improve early stage peripheral lesions endobronchial diagnostic yield without ENB. Additional studies are warranted to confirm its safety, efficacy and technical benefits, both for diagnosis of oncological and non-oncological disease and for endobronchial treatment of inoperable patients.
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Affiliation(s)
- Roberto Piro
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42123, Reggio Emilia, Italy.
| | - Matteo Fontana
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42123, Reggio Emilia, Italy
| | - Eleonora Casalini
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42123, Reggio Emilia, Italy
| | - Sofia Taddei
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42123, Reggio Emilia, Italy
| | - Marco Bertolini
- Medical Physics Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42123, Reggio Emilia, Italy
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16
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4D Electromagnetic Navigation Bronchoscopy for the Sampling of Pulmonary Lesions: First European Real-Life Experience. Lung 2021; 199:493-500. [PMID: 34562105 PMCID: PMC8510943 DOI: 10.1007/s00408-021-00477-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/12/2021] [Indexed: 12/19/2022]
Abstract
Purpose The use of Electromagnetic navigation bronchoscopy (ENB) for the diagnosis of pulmonary peripheral lesions is still debated due to its variable diagnostic yield; a new 4D ENB system, acquiring inspiratory and expiratory computed tomography (CT) scans, overcomes respiratory motion and uses tracked sampling instruments, reaching higher diagnostic yields. We aimed at evaluating diagnostic yield and accuracy of a 4D ENB system in sampling pulmonary lesions and at describing their influencing factors. Methods We conducted a three-year retrospective observational study including all patients with pulmonary lesions who underwent 4D ENB with diagnostic purposes; all the factors potentially influencing diagnosis were recorded. Results 103 ENB procedures were included; diagnostic yield and accuracy were, respectively, 55.3% and 66.3%. We reported a navigation success rate of 80.6% and a diagnosis with ENB was achieved in 68.3% of cases; sensitivity for malignancy was 61.8%. The majority of lesions had a bronchus sign on CT, but only the size of lesions influenced ENB diagnosis (p < 0.05). Transbronchial needle aspiration biopsy was the most used tool (93.2% of times) with the higher diagnostic rate (70.2%). We reported only one case of pneumothorax. Conclusion The diagnostic performance of a 4D ENB system is lower than other previous navigation systems used in research settings. Several factors still influence the reachability of the lesion and therefore diagnostic yield. Patient selection, as well as the multimodality approach of the lesion, is strongly recommended to obtain higher diagnostic yield and accuracy, with a low rate of complications.
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17
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Chen J, Xie F, Zheng X, Li Y, Liu S, Ma KC, Goto T, Müller T, Chan ED, Sun J. Mobile 3-dimensional (3D) C-arm system-assisted transbronchial biopsy and ablation for ground-glass opacity pulmonary nodules: a case report. Transl Lung Cancer Res 2021; 10:3312-3319. [PMID: 34430367 PMCID: PMC8350092 DOI: 10.21037/tlcr-21-561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/22/2021] [Indexed: 01/15/2023]
Abstract
Identification of pulmonary ground-glass opacity (GGO) lesions during bronchoscopic procedures remains challenging, as GGOs cannot be directly visualized under 2-dimensional (2D) fluoroscopy and are often difficult to detect by radial endobronchial ultrasound. Recently, a mobile 2D/3D C-arm fluoroscopy system was developed that provides both 2D fluoroscopy and mobile 3D imaging to assess and confirm the location of the lesions and ancillary bronchoscopic tools. However, previous studies focused mainly on experience of utilizing mobile 3D C-arm system for transbronchial biopsy of solid pulmonary nodules. Here, we evaluated the feasibility of mobile 3D imaging assisted transbronchial biopsy with and without ablation of two patients with GGO nodules. The first patient underwent biopsy only, and the second patient underwent biopsy in the right upper lobe lung nodule and ablation of a left upper lobe lung nodule in one session. Procedures in both patients were successfully performed, and no significant complications have been observed intra- or post-procedurally. Our case study highlights the potential value of the mobile 3D imaging system in accurate identification of the target lung lesion, confirmation of bronchoscopic tools within the lesion, and assessment of the target lesion and surrounding tissue following bronchoscopic ablation procedure. Furthermore, a “one-stop shop” bronchoscopy workflow combining both biopsy and ablation for one or more lung lesions in one session could be made possible by utilizing a hybrid mobile 2D/3D C-arm system in the bronchoscopy suite.
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Affiliation(s)
- Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Ying Li
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Shuaiyang Liu
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Kevin C Ma
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, & Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Taichiro Goto
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital, Yamanashi, Japan
| | - Tobias Müller
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
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18
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Verhoeven RLJ, Vos S, van der Heijden EHFM. Multi-modal tissue sampling in cone beam CT guided navigation bronchoscopy: comparative accuracy of different sampling tools and rapid on-site evaluation of cytopathology. J Thorac Dis 2021; 13:4396-4406. [PMID: 34422366 PMCID: PMC8339773 DOI: 10.21037/jtd-21-518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/23/2021] [Indexed: 12/26/2022]
Abstract
Background Advanced technological aids are frequently used to improve outcome of transbronchial diagnostics for peripheral pulmonary lesions. Even when lesion access has been confirmed by 3D imaging, obtaining an accurate tissue sample however remains difficult. In this single institution study, we evaluate the comparative accuracy of different sampling methodologies and the accuracy of rapid on-site evaluation of cytopathology (ROSE) in navigation bronchoscopy cases where imaging has confirmed the catheter to have accurately accessed the lesion. Methods All consecutive navigation bronchoscopies in between December 2017– June 2020 performed in a room with a cone beam CT (CBCT) system where catheter position was intra-procedurally confirmed to be within or adjacent to the lesion by cone beam CT and augmented fluoroscopy were included. Individual tool outcomes were compared against one another and follow-up outcome. Results A mean of 11.39 samples using 2.93 tools were obtained in 225 lesions (median diameter 15 mm, 195 patients). A correct diagnosis was most often obtained by forceps (accuracy 70.6%), followed by 1.1 mm cryoprobe (68.4%), needle aspiration (46.7%), 1.9 mm cryoprobe (41.2%), brush (30.3%) and lavage (23.7%). Procedural outcome corresponded to follow-up outcome in 75.1% of lesions (80.5% of patients). Accurately diagnosed lesions were sampled significantly more often (11.91 vs. 9.72 samples, P=0.014). In cases where procedural outcome proved malignant, ROSE had also detected this in 47.5%. Conclusions Of all clinically available biopsy tools, the forceps showed most often accurate. However, extensive multi-modal sampling resulted in highest diagnostic accuracy. A hypothetical multi-modal approach of only using forceps and needle aspiration provided eventual diagnostic outcome in 91.7% of successfully diagnosed lesions. In the circumstances of our study, confirmation of malignancy on ROSE did not reduce number of biopsies taken nor biopsy time. Future research on how to improve the accuracy and effectivity of tissue sampling is needed.
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Affiliation(s)
- Roel L J Verhoeven
- Department of Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shoko Vos
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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de Ruiter QMB, Fontana JR, Pritchard WF, Mauda-Havakuk M, Bakhutashvili I, Esparza-Trujillo JA, Varble NA, Verstege M, Xu S, Seifabadi R, Browning RF, Wood BJ, Karanian JW. Endovascular steerable and endobronchial precurved guiding sheaths for transbronchial needle delivery under augmented fluoroscopy and cone beam CT image guidance. Transl Lung Cancer Res 2021; 10:3627-3644. [PMID: 34584862 PMCID: PMC8435394 DOI: 10.21037/tlcr-21-275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endobronchial navigation is performed in a variety of ways, none of which are meeting all the clinicians' needs required to reach diagnostic success in every patient. We sought to characterize precurved and steerable guiding sheaths (GS) in endobronchial targeting for lung biopsy using cone beam computed tomography (CBCT) based augmented fluoroscopy (AF) image guidance. METHODS Four precurved GS (EdgeTM 45, 90, 180, 180EW, Medtronic) and two steerable GS [6.5 F Destino Twist (DT), Oscor; 6 F Morph, BioCardia] were evaluated alone and in combination with an electromagnetic tracking (EM) guide and biopsy needles in three experimental phases: (I) bench model to assess GS deflection and perform biopsy simulations; (II) ex vivo swine lung comparing 2 steerable and 2 precurved GS; and (III) in vivo male swine lung to deliver a needle (n=2 swine) or to deliver a fiducial marker (n=2 swine) using 2 steerable GS. Ex vivo and in vivo image guidance was performed with either commercial or prototype AF image guidance software (Philips) based on either prior CT or procedural CBCT. Primary outcomes were GS delivery angle (θGS) and needle delivery angle (θN) in bench evaluation and needle delivery error (mm) (mean ± se) for ex vivo and in vivo studies. RESULTS The steerable DT had the largest range of GS delivery angles (θN: 0-114°) with either the 21 G or 19 G biopsy needle in the bench model. In ex vivo swine lung, needle delivery errors were 8.7±0.9 mm (precurved Edge 90), 5.4±1.9 mm (precurved Edge 180), 4.7±1.2 mm (steerable DT), and 5.6±2.4 mm (steerable Morph). In vivo, the needle delivery errors for the steerable GS were 6.0±1.0 mm (DT) and 15±7.0 mm (Morph). In vivo marker coil delivery was successful for both the steerable DT and morph GS. A case report demonstrated successful needle biopsy with the steerable DT. CONCLUSIONS Endobronchial needle delivery with AF guidance is feasible without a bronchoscope with steerable GS providing comparable or improved accuracy compared to precurved GS.
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Affiliation(s)
- Quirina M. B. de Ruiter
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Joseph R. Fontana
- Pulmonary Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - William F. Pritchard
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Michal Mauda-Havakuk
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Ivane Bakhutashvili
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Juan A. Esparza-Trujillo
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Nicole A. Varble
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
- Philips Research of North America, Cambridge, MA, USA
| | | | - Sheng Xu
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Reza Seifabadi
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | | | - Bradford J. Wood
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
- Center for Cancer Research, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - John W. Karanian
- Center for Interventional Oncology, Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
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20
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Masaki F, King F, Kato T, Tsukada H, Colson Y, Hata N. Technical validation of multi-section robotic bronchoscope with first person view control for transbronchial biopsies of peripheral lung. IEEE Trans Biomed Eng 2021; 68:3534-3542. [PMID: 33945467 DOI: 10.1109/tbme.2021.3077356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study aims to validate the advantage of the new engineering method to maneuver multi-section robotic bronchoscope with first person view control in transbronchial biopsy. Six physician operators were recruited and tasked to operate a manual and a robotic bronchoscope to the peripheral area placed in patient-derived lung phantoms. The metrics collected were the furthest generation count of the airway the bronchoscope reached, force incurred to the phantoms, and NASA-Task Load Index. The furthest generation count of the airway the physicians reached using the manual and the robotic bronchoscopes were 6.6 +/- 1.2th and 6.7 +/- 0.8th. Robotic bronchoscopes successfully reached the 5th generation count into the peripheral area of the airway, while the manual bronchoscope typically failed earlier in the 3rd generation. More force was incurred to the airway when the manual bronchoscope was used (0.24 +/- 0.20 [N]) than the robotic bronchoscope was applied (0.18 +/- 0.22 [N], p<0.05). The manual bronchoscope imposed more physical demand than the robotic bronchoscope by NASA-TLX score (55 +/- 24 vs 19 +/- 16, p<0.05). These results indicate that a robotic bronchoscope facilitates the advancement of the bronchoscope to the peripheral area with less physical demand to physician operators. The metrics collected in this study would expect to be used as a benchmark for the future development of robotic bronchoscopes.
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21
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Kalanjeri S, Abbasi A, Luthra M, Johnson JC. Invasive modalities for the diagnosis of peripheral lung nodules. Expert Rev Respir Med 2021; 15:781-790. [PMID: 33899654 DOI: 10.1080/17476348.2021.1913059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lung nodules are being increasingly discovered either incidentally or through lung cancer screening chest CT scans. Some of these will turn out to be malignant and therefore it is important to obtain an accurate and timely diagnosis of lung cancer when suspected. AREAS COVERED This review will cover various invasive diagnostic modalities available to sample lung nodules. Data from key studies, obtained from PubMed searches, will be reviewed. Emerging technologies such as cone-beam CT and robotic-assisted bronchoscopies will be discussed along with ddata available currently to support their use. EXPERT OPINION The best approach to diagnosing a lung nodule - whether found incidentally or because of lung cancer screening - is continuously evolving. While CT-guided lung nodule biopsy has a high diagnostic yield, the risk of pneumothorax is often a concern. Bronchoscopy has a better safety profile, but diagnostic ability falls short of CT-guided biopsy. Existing technologies such as electromagnetic navigation have not demonstrated a high diagnostic yield. Factors responsible for this relatively lower low diagnostic yield will be discussed in detail. Emerging technologies such as cone-beam CT scan and robotic bronchoscopy have addressed some of these issues and initial experience has demonstrated better diagnostic yield.
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Affiliation(s)
- Satish Kalanjeri
- Pulmonary and Critical Care Medicine, Harry S. Truman Memorial Veterans Hospital, University of Missouri School of Medicine, Columbia, MO, USA
| | - Anna Abbasi
- Anna Abbasi, Pulmonary and Critical Care Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Munish Luthra
- Munish Luthra, Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeremy C Johnson
- Pulmonary and Critical Care Medicine, Harry S. Truman Memorial Veterans Hospital, University of Missouri School of Medicine, Columbia, MO, USA
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22
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Kawakita N, Takizawa H, Toba H, Sakamoto S, Miyamoto N, Matsumoto D, Takashima M, Tsuboi M, Yoshida M, Kawakami Y, Kondo K, Tangoku A. Cone-beam computed tomography versus computed tomography-guided ultrathin bronchoscopic diagnosis for peripheral pulmonary lesions: A propensity score-matched analysis. Respirology 2021; 26:477-484. [PMID: 33615626 DOI: 10.1111/resp.14016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/15/2021] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE CBCT-guided TBB using a UTB under VBN is a useful method for the diagnosis of peripheral small pulmonary lesions. CBCT-guided TBB using UTB under VBN has been used as an alternative to CT-guided TBB. However, the advantage of CBCT-guided TBB using UTB under VBN over CT-guided TBB is still unknown. This study aimed to compare the diagnostic yield of CT-guided TBB and CBCT-guided TBB using a propensity score-matched analysis. METHODS Patients with peripheral pulmonary lesions ≤30 mm were included. Lesions whose bronchus could not be determined by CT were excluded. A UTB and biopsy forceps were advanced to the target bronchus under VBN, 2D-fluoroscopy and CT or CBCT. The CT-guided and CBCT-guided groups were matched for their propensity scores based on patient characteristics. RESULTS We retrospectively reviewed 93 patients in the CT-guided group and 79 patients in the CBCT-guided group for this study. Furthermore, 48 distinct examination pairs were generated by propensity score matching. In the overall diagnostic yield, the CBCT-guided group showed better results (72.9%) than did the CT-guided group (47.9%) (P = 0.012). The median examination time lasted for 43 (IQR: 37-51) min in the CBCT-guided group and 50 (IQR: 43-62) min in the CT-guided group. The examination time in the CBCT-guided group was significantly shorter than that of the CT-guided group (P = 0.001). CONCLUSION CBCT-guided TBB had a better diagnostic yield and shorter examination time than did CT-guided TBB.
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Affiliation(s)
- Naoya Kawakita
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Hiromitsu Takizawa
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Hiroaki Toba
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Shinichi Sakamoto
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Naoki Miyamoto
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Daisuke Matsumoto
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Mika Takashima
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Mitsuhiro Tsuboi
- Department of Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Mitsuteru Yoshida
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Yukikiyo Kawakami
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Kazuya Kondo
- Department of Oncological Medical Services, Graduate School of Biomedical Biosciences, Tokushima University, Tokushima, Japan
| | - Akira Tangoku
- Department of Thoracic and Endocrine Surgery and Oncology, Institute of Biomedical Sciences, The University of Tokushima Graduate School, Tokushima, Japan
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23
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Kheir F, Thakore SR, Uribe Becerra JP, Tahboub M, Kamat R, Abdelghani R, Fernandez-Bussy S, Kaphle UR, Majid A. Cone-Beam Computed Tomography-Guided Electromagnetic Navigation for Peripheral Lung Nodules. Respiration 2021; 100:44-51. [PMID: 33401270 DOI: 10.1159/000510763] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive technology for the diagnosis of peripheral pulmonary nodules. However, ENB is limited by the lack of real-time confirmation of various biopsy devices. Cone-beam computed tomography (CBCT) could increase diagnostic yield by allowing real-time confirmation to overcome the inherent divergence of nodule location. OBJECTIVES The aim of this study was to assess the diagnostic yield of ENB plus CBCT as compared with ENB alone for biopsy of peripheral lung nodules. METHOD We conducted a retrospective study of patients undergoing ENB before and after the implementation of CBCT. Data from 62 consecutive patients with lung nodules located in the outer two-thirds of the lung who underwent ENB and combined ENB-CBCT were collected. Radial endobronchial ultrasound was used during all procedures as well. Diagnostic yield was defined as the presence of malignancy or benign histological findings that lead to a specific diagnosis. RESULTS Thirty-one patients had ENB-CBCT, and 31 patients had only ENB for peripheral lung lesions. The median size of the lesion for the ENB-CBCT group was 16 (interquartile range (IQR) 12.6-25.5) mm as compared to 21.5 (IQR 16-27) mm in the ENB group (p = 0.2). In the univariate analysis, the diagnostic yield of ENB-CBCT was 74.2% and ENB 51.6% (p = 0.05). Following multivariate regression analysis adjusting for the size of the lesion, distance from the pleura, and presence of bronchus sign, the odds ratio for the diagnostic yield was 3.4 (95% CI 1.03-11.26, p = 0.04) in the ENB-CBCT group as compared with ENB alone. The median time for the procedure was shorter in patients in the ENB-CBCT group (74 min) than in those in the ENB group (90 min) (p = 0.02). The rate of adverse events was similar in both groups (6.5%, p = 0.7). CONCLUSIONS The use of CBCT might increase the diagnostic yield in ENB-guided peripheral lung nodule biopsies. Future randomized clinical trials are needed to confirm such findings.
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Affiliation(s)
- Fayez Kheir
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanket R Thakore
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Interventional Pulmonary, Department of Pulmonary, Critical Care and Sleep Medicine, Yale University, New Haven, Connecticut, USA
| | - Juan Pablo Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad Tahboub
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Rahul Kamat
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Ramsy Abdelghani
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Upendra R Kaphle
- Division of Pulmonary and Critical Care, Kaiser Permanente Roseville and Sacramento Medical Center, Roseville, California, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA,
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24
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Pritchett MA, Bhadra K, Mattingley JS. Electromagnetic Navigation Bronchoscopy With Tomosynthesis-based Visualization and Positional Correction: Three-dimensional Accuracy as Confirmed by Cone-Beam Computed Tomography. J Bronchology Interv Pulmonol 2021; 28:10-20. [PMID: 32412920 PMCID: PMC7742212 DOI: 10.1097/lbr.0000000000000687] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, anatomic divergence between the preprocedural computed tomography (CT) and the actual bronchial anatomy during the procedure can limit localization accuracy. An advanced ENB system has been designed to mitigate CT-to-body divergence using a tomosynthesis-based software algorithm that enhances nodule visibility and allows for intraprocedural local registration. MATERIALS AND METHODS A prospective, 2-center study was conducted in subjects with single peripheral lung lesions ≥10 mm to assess localization accuracy of the superDimension navigation system with fluoroscopic navigation technology. Three-dimensional accuracy was confirmed by cone-beam computed tomography. Complications were assessed through 7 days. RESULTS Fifty subjects were enrolled (25 per site). Lesions were <20 mm in 61.2% (30/49). A bronchus sign was present in 53.1% (26/49). Local registration was completed in 95.9% (47/49). Three-dimensional target overlap (primary endpoint) was achieved in 59.6% (28/47) and 83.0% (39/47) before and after location correction, respectively. Excluding subjects with unevaluable video files, target overlap was achieved 68.3% (28/41) and 95.1% (39/41), respectively. Malignant results were obtained in 53.1% (26/49) by rapid on-site evaluation and 61.2% (30/49) by final pathology of the ENB-aided sample. Diagnostic yield was not evaluated. Procedure-related complications were pneumothorax in 1 subject (no chest tube required) and scant hemoptysis in 3 subjects (no interventions required). CONCLUSION ENB with tomosynthesis-based fluoroscopic navigation improved the 3-dimensional convergence between the virtual target and actual lung lesion as confirmed by cone-beam computed tomography. Future studies are necessary to understand the impact of this technology on diagnostic yield.
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Affiliation(s)
| | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN
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25
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Oki M, Saka H. Diagnostic value of ultrathin bronchoscopy in peripheral pulmonary lesions: a narrative review. J Thorac Dis 2020; 12:7675-7682. [PMID: 33447460 PMCID: PMC7797850 DOI: 10.21037/jtd-2020-abpd-001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Flexible bronchoscopes are being continuously improved, and an ultrathin bronchoscope with a working channel that allows the use of a radial-type endobronchial ultrasound (EBUS) probe is now available. The ultrathin bronchoscope has good maneuverability for passing through the small bronchi and good accessibility to peripheral lung lesions. This utility is particularly enhanced when it is used with other imaging devices, such as EBUS and navigation devices. Multimodality bronchoscopy using an ultrathin bronchoscope leads to enhanced diagnostic yield.
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Affiliation(s)
- Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.,Department of Respiratory Medicine, Matsunami General Hospital, Kasamatsu, Japan
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26
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Abstract
Navigation bronchoscopy has reached a new horizon in its evolution. Combining with real-time imaging modalities, such as cone-beam computed tomography (CBCT) and augmented fluoroscopy (AF), navigation success can finally be confirmed with high degree of accuracy in real-time. With utilization of this modality, additional clinical observations are being made to help address the CT-body divergence problem and further improve navigation accuracy. This review focuses on description of CBCT navigation technique, provide tips on addressing CT-Body divergence, and review evidence for CBCT applications in navigation bronchoscopy.
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Affiliation(s)
- George Z Cheng
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lihua Liu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, CA, USA.,Division of Pulmonary and Critical Care Medicine, First Affiliated Hospital, Guangxi Medical University, Nanning 530021, China
| | - Matthew Nobari
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Russell Miller
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Department of Pulmonary and Critical Care, Naval Medical Center San Diego, San Diego, CA, USA
| | - Momen Wahidi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, CA, USA
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27
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Pritchett MA, Bhadra K, Calcutt M, Folch E. Virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy. J Thorac Dis 2020; 12:1595-1611. [PMID: 32395297 PMCID: PMC7212155 DOI: 10.21037/jtd.2020.01.35] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Guided bronchoscopy offers a minimally invasive and safe method for accessing indeterminate pulmonary nodules. However, all current guided bronchoscopy systems rely on a preprocedural computed tomography (CT) scan to create a virtual map of the patient's airways. Changes in lung anatomy between the preprocedural CT scan and the bronchoscopy procedure can lead to a divergence between the expected and actual location of the target lesion. Termed "CT-to-body divergence", this effect reduces diagnostic yield, adds time to the procedure, and can be challenging for the operator. The objective of this paper is to describe the concept of CT-to-body divergence, its contributing factors, and methods and technologies that might minimize its deleterious effects on diagnostic yield.
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Affiliation(s)
- Michael A Pritchett
- FirstHealth of the Carolinas and Pinehurst Medical Clinic, Pinehurst, NC, USA
| | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN, USA
| | - Mike Calcutt
- Clinical Education, Medtronic, Minneapolis, MN, USA
| | - Erik Folch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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28
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Fielding D, Oki M. Technologies for targeting the peripheral pulmonary nodule including robotics. Respirology 2020; 25:914-923. [PMID: 32103596 DOI: 10.1111/resp.13791] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 12/26/2022]
Abstract
Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground-glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes.
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Affiliation(s)
- David Fielding
- Department of Thoracic Medicine, Royal Brisbane Women's Hospital, Brisbane, QLD, Australia
| | - Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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