Design of a prospective, multicenter, global, cohort study of electromagnetic navigation bronchoscopy

An alternative bronchoscopic transparenchymal nodule access by "invisible tunnel" technique under electromagnetic navigation without the transbronchial access tool

BACKGROUND

The diagnosis of peripheral pulmonary lesions (PPL) is still challenging. We describe a novel method for sampling PPL without bronchial signs by creating invisible tunnel under electromagnetic navigation without the transbronchial access tool (TABT).

METHODS

During electromagnetic navigation, we adjust the angle of the edge extended working channel catheter based on the real-time position of the lesion in relation to the locating guide rather than preset route. A biopsy brush or biopsy forceps is used to punch a hole in the bronchial wall. A locating guide is then re-inserted to real-time navigate through the lung parenchyma to the lesion. Safety and feasibility of this method was analyzed.

RESULTS

A total of 32 patients who underwent electromagnetic navigation bronchoscopy were retrieved. The mean size of the lesion is 23.1 mm. The mean operative time of all patients was 12.4 min. Ten of the patients did not have a direct airway to the lesion, thus creating an invisible tunnel. For them, the length of the tunnel from the bronchial wall POE to the lesion was 11-30 mm, with a mean length of 16.9 mm and a mean operation time of 14.1 min. Adequate samples were obtained from 32 patients (100%), and the diagnostic yield was 87.5% (28/32). Diagnostic yield of with create the invisible tunnel TBAT was 90% (9/10), and one patient undergone pneumothorax after operation.

CONCLUSIONS

This method is feasible and safe as a novel approach sampling pulmonary lesions without bronchial signs, and it further improves current tunnel technique.

Safety and risk factors for bleeding complications of radial probe endobronchial ultrasound-guided transbronchial biopsy

BACKGROUND

Radial probe endobronchial ultrasound (radial EBUS) is widely used to diagnose pulmonary lesions; however, the diagnostic value of radial EBUS-guided transbronchial biopsy (TBB) varies, and its complications (especially the risk of bleeding) are not properly understood.

OBJECTIVES

In this study, we evaluated the diagnostic performance and rate of complication of this procedure, and investigated the risk factors associated with the procedure-related bleeding events.

DESIGN

A retrospective cohort study.

METHODS

This was a retrospective study that included consecutive patients who underwent radial EBUS-guided TBB. Radial EBUS was performed under moderate sedation in inpatients or outpatients. The severity of bleeding was graded using the standardized definitions of bleeding.

RESULTS

Of 133 patients (median age, 69 years; men 57.1%) included, 41 were outpatients (30.8%). The diagnostic accuracy, sensitivity, and specificity for malignancy were 76.1% (89/117), 71.1% (69/97), and 100% (20/20), respectively. The diagnostic accuracy ranged from 66.9% to 79.0%, depending on the classification of undiagnosed cases as either false negatives or true negatives. Twenty-seven patients (20.3%) developed complications (pneumothorax, 3; pneumonia, 5; complicated pleural effusion, 2; bleeding event grade 2 or higher, 21). Of the 41 outpatients, two developed complications (pneumothorax without intervention, 1; grade 2 bleeding event, 1). Of the 21 patients (15.8%) with procedure-related bleeding events, 18 had grade 2, and three had grade 3 bleeding complications. In multivariate analysis, a large size of ⩾30 mm (adjusted odds ratio (OR), 5.09; p = 0.03) and central lesion (adjusted OR, 3.67; p = 0.03) were significantly associated with the risk of grade 2 or higher bleeding events.

CONCLUSION

Our results suggest that radial EBUS-guided TBB is an accurate and safe method for diagnosing pulmonary lesions. Clinically significant procedure-related bleeding was rare. The central location and larger size (⩾30 mm) of pulmonary lesions were risk factors for grade 2 or higher bleeding events.

When Pulmonologists Are Novice to Navigational Bronchoscopy, What Predicts Diagnostic Yield?

Predicting factors of diagnostic yield in electromagnetic navigation bronchoscopy (ENB) have been explored in a number of previous studies based on data from experienced operators. However, little is known about predicting factors when the procedure is carried out by operators in the beginning of their learning curve. We here aim to identify the role of operators' experience as well as lesion- and procedure characteristics on diagnostic yield of ENB procedures in the hands of novice ENB operators. Four operators from three centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or non-diagnostic and predicting factors of diagnostic yield were assessed. A total of 215 procedures were assessed. A total of 122 (57%) of the ENB procedures resulted in diagnostic biopsies. Diagnostic ENB procedures were associated with a minor yet significant difference in tumor size compared to non-diagnostic/inconclusive ENB procedures (28 mm vs. 24 mm; p = 0.03). Diagnostic ENB procedures were associated with visible lesions at either fluoroscopy (p = 0.003) or radial endobronchial ultrasound (rEBUS), (p = 0.001). In the logistic regression model, lesion visibility on fluoroscopy, but none of operator experience, the presence of a bronchus sign, lesion size, or location nor visibility on rEBUS significantly impacted the diagnostic yield. In novice ENB operators, lesion visibility on fluoroscopy was the only factor found to increase the chance of obtaining a diagnostic sample.

Shape-Sensing Robotic-Assisted Bronchoscopy vs Digital Tomosynthesis-Corrected Electromagnetic Navigation Bronchoscopy: A Comparative Cohort Study of Diagnostic Performance

BACKGROUND

Electromagnetic navigational bronchoscopy has been the dominant bronchoscopic technology for targeting small peripheral lesions and now includes digital tomosynthesis-electromagnetic navigational bronchoscopy (DT-ENB), allowing near-real-time intraprocedural nodule visualization. Shape-sensing robotic-assisted bronchoscopy (ssRAB), with improved catheter stability and articulation recently became available. Although the diagnostic performance of these two methods seems higher than that of legacy systems, data remain limited. We sought to compare the diagnostic yield of these two novel platforms after their introduction at our institution.

RESEARCH QUESTION

Does the diagnostic yield of ssRAB differ significantly from that of DT-ENB in patients undergoing biopsy of peripheral pulmonary lesions (PPLs)?

STUDY DESIGN AND METHODS

This retrospective comparative cohort study analyzed prospectively collected data on consecutive procedures performed with DT-ENB and ssRAB in their first 6 months of use at our institution. Biopsies were considered diagnostic if histopathologic analysis revealed malignancy or specific benign features that readily explained the presence of a PPL. Nonspecific inflammation, normal lung or airway, and atypia not diagnostic of malignancy were considered nondiagnostic.

RESULTS

SSRAB was used to biopsy 143 PPLs in 133 patients and DT-ENB was used to biopsy 197 PPLs in 170 patients. Diagnostic yield was 77% for ssRAB (110 of 143 PPLs) and 80% (158 of 197 PPLs) for DT-ENB (OR, 0.8; 95% CI, 0.5-1.4; P = .4). Median lesion diameters were 17 and 19 mm, respectively. No difference in diagnostic yield was found after adjustment for lesion size, bronchus sign, peripheral vs middle third location, and sex. Pneumothorax complicated 1.5% of ssRAB and 1.8% of DT-ENB procedures (P = .86).

INTERPRETATION

SSRAB and DT-ENB showed comparable diagnostic yields and safety profiles in this comparative cohort study.

[Application and Progress of Electromagnetic Navigation Bronchoscopy in Department of Thoracic Surgery]

Lung cancer ranks the first cancer-related morbidity and mortality in China. With the development and penetration of imaging technology, increasing small pulmonary peripheral Nodules (SPPNs) have been detected. However, precise location and diagnosis of SPPNs is still a tough problem for clinical diagnosis and treatment in department of thoracic surgery. With the development of electromagnetic navigation bronchoscopy (ENB), it provides a novel minimally invasive method for the diagnosis and treatment of SPPNs. In this review, we summarized the application and progress of ENB in preoperative positioning, diagnosis, and local treatment, then, discussed the clinical application of ENB in the hybrid operating room.
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NAVIGATE 24-Month Results: Electromagnetic navigation bronchoscopy for pulmonary lesions at 37 centers in Europe and the United States

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive, image-guided approach to access lung lesions for biopsy or localization for treatment. However, no studies have reported prospective 24-month follow-up from a large, multinational, generalizable cohort. This study evaluated ENB safety, diagnostic yield, and usage patterns in an unrestricted, real-world observational design.

METHODS

The NAVIGATE single-arm, pragmatic cohort study (NCT02410837) enrolled subjects at 37 academic and community sites in 7 countries with prospective 24-month follow-up. Subjects underwent ENB using the superDimension navigation system versions 6.3 to 7.1. The prespecified primary endpoint was procedure-related pneumothorax requiring intervention or hospitalization.

RESULTS

A total of 1,388 subjects were enrolled for lung lesion biopsy (1,329; 95.7%), fiducial marker placement (272; 19.6%), dye marking (23; 1.7%), and/or lymph node biopsy (36; 2.6%). Concurrent endobronchial ultrasound-guided staging occurred in 456 subjects. General anesthesia (78.2% overall, 56.6% Europe, 81.4% US), radial endobronchial ultrasound (50.6%, 4.0%, 57.4%), fluoroscopy (85.0%, 41.7%, 91.0%), and rapid on-site evaluation use (61.7%, 17.3%, 68.5%) differed between regions. Pneumothorax and bronchopulmonary hemorrhage occurred in 4.7% and 2.7% of subjects, respectively (3.2% [primary endpoint] and 1.7% requiring intervention or hospitalization). Respiratory failure occurred in 0.6%. The diagnostic yield was 67.8% (range 61.9%-70.7%; 55.2% Europe, 69.8% US). Sensitivity for malignancy was 62.6%. Lung cancer clinical stage was I-II in 64.7% (55.3% Europe, 65.8% US).

CONCLUSIONS

Despite a heterogeneous cohort and regional differences in procedural techniques, ENB demonstrates low complications and a 67.8% diagnostic yield while allowing biopsy, staging, fiducial placement, and dye marking in a single procedure.

Clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions

Background

The purpose of this study was to retrospectively evaluate the clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions.

Methods

This was a retrospective study. Patients with peripheral lung lesions in our institution between January 2019 and December 2020, who underwent lung biopsy assisted by the electromagnetic navigation system were included in Group A, and those who underwent lung biopsy using conventional CT-guided percutaneous lung biopsy were included in Group B. The general features and clinical and technical information of each patient were collected and evaluated in both groups.

Results

A total of 141 patients were included in Group A (78 males and 63 females; median age, 65 years; range, 32–79 years), and 96 patients were included in group B (57 males and 39 females; median age, 65 years; range, 34–80 years). The technical success rate was 100% in both groups. The technical efficacy rate was 92.9% and 90.6% in Groups A and B (P=0.525), respectively. There was no significant difference in surgical time and the number of CT scans between the two groups, and only grade 1–2 complications occurred in the patients.

Conclusions

The electromagnetic navigation system is an effective and safe auxiliary tool for CT-guided percutaneous lung biopsy of peripheral lung lesions.

A simple assessment of lung nodule location for reduction in unnecessary invasive procedures

Background

CT screening for lung cancer results in a significant mortality reduction but is complicated by invasive procedures performed for evaluation of the many detected benign nodules. The purpose of this study was to evaluate measures of nodule location within the lung as predictors of malignancy.

Methods

We analyzed images and data from 3,483 participants in the National Lung Screening Trial (NLST). All nodules (4–20 mm) were characterized by 3D geospatial location using a Cartesian coordinate system and evaluated in logistic regression analysis. Model development and probability cutpoint selection was performed in the NLST testing set. The Geospatial test was then validated in the NLST testing set, and subsequently replicated in a new cohort of 147 participants from The Detection of Early Lung Cancer Among Military Personnel (DECAMP) Consortium.

Results

The Geospatial Test, consisting of the superior-inferior distance (Z distance), nodule diameter, and radial distance (carina to nodule) performed well in both the NLST validation set (AUC 0.85) and the DECAMP replication cohort (AUC 0.75). A negative Geospatial Test resulted in a less than 2% risk of cancer across all nodule diameters. The Geospatial Test correctly reclassified 19.7% of indeterminate nodules with a diameter over 6mm as benign, while only incorrectly classifying 1% of cancerous nodules as benign. In contrast, the parsimonious Brock Model applied to the same group of nodules correctly reclassified 64.5% of indeterminate nodules as benign but resulted in misclassification of a cancer as benign in 18.2% of the cases. Applying the Geospatial test would result in reducing invasive procedures performed for benign lesions by 11.3% with a low rate of misclassification (1.3%). In contrast, the Brock model applied to the same group of patients results in decreasing invasive procedures for benign lesion by 39.0% but misclassifying 21.1% of cancers as benign.

Conclusions

Utilizing information about geospatial location within the lung improves risk assessment for indeterminate lung nodules and may reduce unnecessary procedures.

Trial Registration

NCT00047385, NCT01785342.

The Impact of Biopsy Tool Choice and Rapid On-Site Evaluation on Diagnostic Accuracy for Malignant Lesions in the Prospective: Multicenter NAVIGATE Study

BACKGROUND

The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is impacted by biopsy tool strategy and rapid on-site evaluation (ROSE) use. This analysis evaluates usage patterns, accuracy, and safety of tool strategy and ROSE in a multicenter study.

METHODS

NAVIGATE (NCT02410837) evaluates ENB using the superDimension navigation system (versions 6.3 to 7.1). The 1-year analysis included 1215 prospectively enrolled subjects at 29 United States sites. Included herein are 416 subjects who underwent ENB-aided biopsy of a single lung lesion positive for malignancy at 1 year. Use of a restricted number of tools (only biopsy forceps, standard cytology brush, and/or bronchoalveolar lavage) was compared with an extensive multimodal strategy (biopsy forceps, cytology brush, aspirating needle, triple needle cytology brush, needle-tipped cytology brush, core biopsy system, and bronchoalveolar lavage).

RESULTS

Of malignant cases, 86.8% (361/416) of true positive diagnoses were obtained using extensive multimodal strategies. ROSE was used in 300/416 cases. The finding of malignancy by ROSE reduced the total number of tools used. A malignant ROSE call was obtained in 71% (212/300), most (88.7%; 188/212) by the first tool used (49.5% with aspirating needle, 20.2% with cytology brush, 17.0% with forceps). True positive rates were highest for the biopsy forceps (86.9%) and aspirating needle (86.6%). Use of extensive tool strategies did not increase the rates of pneumothorax (5.5% restricted, 2.8% extensive) or bronchopulmonary hemorrhage (3.6% restricted, 1.1% extensive).

CONCLUSION

These results suggest that extensive biopsy tool strategies, including the aspirating needle, may provide higher true positive rates for detecting lung cancer without increasing complications.

Cone-Beam Computed Tomography-Guided Electromagnetic Navigation for Peripheral Lung Nodules

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.

Electromagnetic navigation bronchoscopy as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway: an initial retrospective single centre series

Background

The performance of electromagnetic navigation bronchoscopy (ENB) is reported with substantial variation, which may question its clinical usefulness. However, ENB may hold its true value when used as an additional minimal invasive diagnostic option before potential surgery in selected diagnostically challenging patients where traditional diagnostic methods have failed. We evaluated the safety and performance of ENB when used as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway (DLCDP) and its ability to reduce surgical diagnostic procedures.

Methods

A retrospective study was performed on eighty-two consecutive patients at Odense University Hospital from June 2016 to March 2018 with diagnostically challenging pulmonary lesions referred for ENB as an adjunct diagnostic procedure under the DLCDP. Patients with benign or inconclusive ENB pathology were either referred for further biopsies, surgery or repeated computer tomography (CT) scans for surveillance purposes.

Results

Eighty-one ENB procedures were performed in 80 patients. In 87.7% of the cases previous diagnostic methods had been unsuccessful. The mean target diameter was 1.55 cm and the average follow-up duration was 11 months. The diagnostic accuracy was 75%, while the diagnostic yield/sensitivity, negative predictive value and negative likelihood ratio was 51%, 67% and 0.49, respectively. No pneumothoraces and only one intrapulmonary haemorrhage was recorded, which was managed conservatively. The learning curve revealed an increase in diagnostic accuracy from 67.5% to 82.9% when comparing the first 40 ENB procedures with the last 41 procedures, however, this was not statistically significant (p-value: 0.11).

Conclusions

ENB was found to be a safe procedure with an acceptable diagnostic accuracy and yield in highly selected diagnostically challenging patients. The introduction of ENB carried a notable learning curve but proved to be a valuable adjunct diagnostic option in the DLCDP, which may help to reduce the number of potentially unnecessary or harmful surgical procedures in frail patients.

Bronchoscopic biopsy of peripheral pulmonary lesions in 2020: a review of existing technologies

There are over 200,000 new cases of lung cancer diagnosed annually in the United States resulting in nearly 150,000 deaths, making lung cancer the most lethal of all forms of cancer. Only 1 in 6 lung cancers are diagnosed at an early stage an over half are diagnosed with distant metastasis. Despite advances in screening and treatment, the 5-year survival rate for all lung cancers remains low, around 20%. The advent of effective lung cancer screening with low-dose computed tomography has started to shift diagnosis to earlier stages. Screening, along with the ever-increasing use of chest CT, have led to an exponential increase in the detection of indeterminate lung nodules. For many nodules, effective diagnosis relies on invasive tissue sample collection. Advances in bronchoscopic technology have allowed for safe and increasingly effective tissue diagnosis of these nodules; however, inconsistencies across studies evaluating diagnostic yield remain. This review will provide an overview of the advanced bronchoscopic technologies currently in wide use, the quality of data supporting their use, some of the perceived weaknesses and strengths of each technology, and introduce promising emerging diagnostic platforms poised to advance the field. Ultimately, quality comparative research is needed to accurately characterize the diagnostic test performance of currently available bronchoscopic platforms, improve the efficacy of bronchoscopy-generated diagnostic yields while maintaining, their strong safety profile.

Efficiency of Electromagnetic Navigation Bronchoscopy and Virtual Bronchoscopic Navigation

BACKGROUND

Image-guided bronchoscopy techniques have emerged as a means of improving pulmonary nodule biopsy yield. However comparisons of the diagnostic efficacy of electromagnetic navigation bronchoscopy (ENB) and virtual bronchoscopic navigation (VBN) have not reached a consensus. This meta-analysis evaluates the overall diagnostic yield and accuracy of ENB and VBN for pulmonary nodules.

METHODS

A systematic search was conducted to identify relevant articles. Meta-analysis was used to summarize the sensitivities, specificities, and area under the curve for ENB and VBN.

RESULTS

Thirty-two studies (1981 patients with pulmonary nodules) were included in this analysis. The pooled sensitivity, specificity, and area under the curve (95% confidence interval) of ENB were 0.80 (0.73-0.85), 0.81 (0.71-0.88), and 0.87 (0.84-0.90), respectively. Corresponding VBN values were 0.80 (0.76-0.83), 0.65 (0.56-0.73), and 0.81 (0.78-0.85), respectively. Comparison of the 2 techniques revealed that ENB had higher specificity and area under the curve but no difference in sensitivity.

CONCLUSIONS

Both ENB and VBN are valuable tools in the diagnosis of lung nodules. ENB achieved a higher specificity than VBN in the diagnose of lung nodules, whereas ENB performed better than VBN for pulmonary nodules. These results are due to the real-time positioning function of ENB.

Bronchoscopic navigation and tissue diagnosis

Diagnosis of early-stage lung cancer has become increasingly important as the detection of peripheral pulmonary lesions (PPLs) grows with widespread adoption of CT-based lung cancer screening. Although CT-guided transthoracic needle aspiration has been the standard diagnostic approach for PPLs, transbronchial sampling by bronchoscopy is often performed due to its reduced rate of adverse events. However, the diagnostic yield of conventional bronchoscopy is often poor. Various bronchoscopic technologies have emerged over recent years to address this limitation, including thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), virtual navigation bronchoscopy (VBN), electromagnetic navigation bronchoscopy (ENB), and robotic bronchoscopy. Bronchoscopic transparenchymal nodule access (BTPNA) and transbronchial access tool (TBAT) are novel techniques that leverage navigational bronchoscopic technologies to further improve access to lesions throughout the lung. The devices used for sampling tissue have similarly evolved, such as the introduction of cryobiopsy. These innovative bronchoscopic techniques allows higher diagnostic yield even in small PPLs. Given the complexity of these new techniques and technologies, it is important for physicians to understand their strengths and limitations.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection.

OBJECTIVE

To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study.

METHODS

NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort.

RESULTS

The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24).

CONCLUSION

In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Introduction: The incidence of peripheral pulmonary lesions (PPLs) is growing following the adoption of lung cancer screening by low-dose chest CT. Although CT-guided transthoracic needle aspiration has been the standard method to diagnose PPLs, the field of interventional bronchoscopy is rapidly advancing to overcome complications of the transthoracic approach yet maintain the yield. Areas covered: This article reviews the clinical evidence of recent emerging interventional bronchoscopic techniques for diagnosis of PPLs. Expert opinion: Recent advances in interventional bronchoscopy contribute to not only the safety of transbronchial approaches to PPLs but also the higher diagnostic yield. To perform accurate sampling of PPLs, bronchoscopists must select the correct airway, approach the target as close as possible, and confirm the location of the target before sampling. These key steps can be assisted by recently developed technologies. However, it is important for bronchoscopists to understand the strengths and limitations of these emerging technologies.

Safety of Electromagnetic Navigation Bronchoscopy in Patients With COPD: Results From the NAVIGATE Study

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) aids in the localization of lung lesions for biopsy and/or to guide fiducial or dye marking for stereotactic radiation or surgical localization. This study assessed ENB safety in patients with chronic obstructive pulmonary disease (COPD) and/or poor lung function.

METHODS

NAVIGATE is a prospective, multicenter, observational study of ENB. This substudy analyzed the 1-month follow-up of the first 1000 enrolled subjects. COPD was determined by medical history. Pulmonary function testing (PFT) results were collected if available within 30 days of the procedure. Procedure-related complications were captured.

RESULTS

The analysis included 448 subjects with COPD and 541 without COPD (COPD data missing in 11). One-month follow-up was completed in 93.3%. Subjects with COPD tended to be older, male, and have history of tobacco exposure, asthma, and recent pneumonia. Nodule size, location, and procedure time were similar between groups. There was no statistically significant difference in the procedure-related composite complication rate between groups (7.4% with COPD, 7.8% without COPD, P=0.90). Common Terminology Criteria for Adverse Events scale grade ≥2 pneumothorax was not different between groups (2.7% with COPD, 3.7% without COPD, P=0.47). COPD was not a significant multivariate predictor of complications. Severity of forced expiratory volume in 1 second (FEV1) or diffusing capacity of the lung for carbon monoxide impairment was not associated with increased composite procedure-related complications (ppFEV1 P=0.66, ppDLCO P=0.36).

CONCLUSION

In this analysis, complication rates following ENB procedures were not increased in patients with COPD or poor pulmonary function. Because pneumothorax risk is not elevated, ENB may be the preferred method to biopsy peripheral lung lesions in patients with COPD and/or poor pulmonary function testing.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study

BACKGROUND

Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB).

METHODS

NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing.

RESULTS

Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages.

CONCLUSION

ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02410837.

A novel diagnostic approach for Pneumocystis jirovecii pneumonia using fine-needle aspiration, electromagnetic navigational bronchoscopy and rapid on-site evaluation

Cavitary lung lesions are common in patients with human immunodeficiency virus infections. Both atypical infections and thoracic malignancies can manifest as a cavitary pulmonary lesion. Standard bronchoscopy is commonly used to evaluate these abnormalities but is limited in its ability to fully assess for cancer and infection. Bronchoalveolar lavage samples are likely to aid in the diagnosis of infection but are less useful in the evaluation of malignancy. In addition, many of these pulmonary lesions are located in the periphery of the lung and are not accessible for tissue sampling by standard bronchoscopy. We present a unique presentation of Pneumocystis jirovecii pneumonia and discuss the utility of electromagnetic navigational bronchoscopy in the evaluation of immunocompromised patients with peripheral cavitary lung lesion.

[Advancement of Common Localization of Solitary Pulmonary Nodules for Video-assisted Thracoscopic Surgery]

最近，伴随着高分辨多层电子计算机断层扫描（computed tomography, CT）的大量普及，肺小结节的诊断也日益增多，尤其是在伴有肺癌高危因素的患者行CT筛查时尤为明显。电视辅助胸腔镜手术对于肺小结节的诊断和治疗提供了一种全新的微创治疗方式，胸腔镜手术后给患者带来的疼痛感减少、住院时间缩短、手术并发症减少等特点，使其推广更为广泛。如何精准定位及标记病灶，以助电视胸腔镜下切除病灶的方法层出不穷。本文综述近年来胸腔镜下肺小结节定位的各种技术手段，并对各种方法的利弊进行总结及分析。

New trends in interventional pulmonology

PURPOSE OF REVIEW

As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications.

RECENT FINDINGS

The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia.

SUMMARY

The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Bronchoscopy for the diagnosis of peripheral lung lesions

Peripheral pulmonary lesions (PPLs) are generally considered as lesions in the peripheral one-third of the lung although a precise definition and radiographic anatomical landmarks separating central and peripheral lesion does not yet exist. The radiographic detection of such lesions has increased significantly with the adoption of lung cancer screening programs. These lesions are not directly visible by regular flexible bronchoscopes as they are usually distal to the lobar and segmental bronchi. Traditionally, depending on location and clinical stage at presentation, these lesions were typically sampled by computerized tomography (CT) guided needle or surgical biopsy although some centers also used ultrasound and fluoroscopy guided percutaneous needle biopsy. Due to lack of direct visualization, the yield for bronchoscopic guided sampling especially of the small <2 cm pulmonary nodules was very low. Therefore, sampling has been preferentially performed by percutaneous CT guidance, which had high yield of above 90% but it comes at the cost of higher risk complications like pneumothorax with reported rate of 15% to 28%. Directly proceeding to surgical resection is also considered in appropriate candidates with high suspicion of malignancy without any evidence of distant metastasis but the proportion of such cases of lung cancer is low. The manuscript discussed the various bronchoscopic diagnostic modalities for peripheral pulmonary lesions. It is important to note that most of the studies in this field are relatively small, not randomized, suffer from selection bias, have considerable heterogeneity in sampling methodology/instruments and usually have been performed in high volume institutions by dedicated highly experienced proceduralists. The prevalence of malignancy in most of the reported cohorts has also been high which may result in higher diagnostic yields. All these factors need to be kept in mind before generalizing the results to individual centers and practices.

The introduction of electromagnetic navigation bronchoscopy for the diagnosis of small pulmonary peripheral lesions in an Asian population

Background

Electromagnetic navigation bronchoscopy (ENB) is emerging as a useful new technique for diagnosing small pulmonary peripheral lesions (SPPLs). However, the accuracy and efficiency of ENB have not been investigated in Asian populations where the differential diagnoses for SPPLs may be different. To analyze this question, this study included patients who received diagnostic ENB followed by surgery for the excision of SPPLs.

Methods

Consecutive patients referred to the Department of Thoracic Surgery, Shanghai Pulmonary Hospital (Tongji University), between May 2014 and April 2015 were recruited. ENB was used to obtain biopsy tissue and make a diagnosis, which was then confirmed by histopathological examination.

Results

The ENB was performed on 84 SPPLs of 78 patients in the study, with four patients having more than one SPPL. It successfully reached and biopsied 81 lesions. The average ENB navigation time was 10.8 minutes (range, 0.5-52 minutes). No mortality occurred, with only two complications (one bleeding and one pneumothorax). The mean diameter of the biopsied SPPLs was 19.0 mm (range, 5.0-30.0 mm). The distance from the sensor probe to the focus was 8.0 mm (range, 1-16 mm). ENB diagnosis had identical results with histopathology examination in 81 lesions (37 lung cancer and 41 non-lung cancer). The sensitivity of ENB was 92.9% (78 out of 84 lesions) in this study.

Conclusions

These data suggested that ENB was an accurate and efficient procedure to sample and diagnose SPPLs in the Asian population. It appeared that ENB had a high percentage of successful results in both navigating and aiding in the diagnosis of SPPLs in the Asian population.

Severe Chronic Obstructive Pulmonary Disease Is Not Associated With Complications After Navigational Bronchoscopy Procedures

BACKGROUND

Electromagnetic navigational bronchoscopy (ENB) is a commonly used technique to obtain biopsies of peripheral pulmonary lesions. Little is known about risk factors for complications with this procedure. The aim of this study was to assess the complication rate associated with ENB and the relationship of complications to patient- and procedure-related factors.

METHODS

Consecutive ENB procedures at an academic medical center between May 11, 2011, and September 11, 2015, were reviewed retrospectively. Preoperative characteristics, including pulmonary function, procedure characteristics, and the occurrence of complications, were recorded.

RESULTS

In all, 361 procedures were performed on 341 patients. Complications occurred in 30 of 361 (8.3%), the most common of which was pneumothorax (27, 7.5%). Complications were not related to age, sex, American Society of Anesthesiologists grade, or pulmonary function test result. Patients with complications had longer procedure times (50 versus 73 minutes, p = 0.03), and had more interventional modalities used (2.4 versus 3.2, p = 0.001). Multiple logistic regression demonstrated that bronchoalveolar lavage was significantly associated with complications (odds ratio 6.40; 95% confidence interval: 1.68 to 24.3, p = 0.006).

CONCLUSIONS

Electromagnetic navigational bronchoscopy is safe, and the rate of complications is not elevated among patients with poor lung function. Bronchoalveolar lavage performed during ENB was associated with elevated risk of complications and should be studied further.

Electromagnetic navigation bronchoscopy to access lung lesions in 1,000 subjects: first results of the prospective, multicenter NAVIGATE study

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) is an image-guided, minimally invasive approach that uses a flexible catheter to access pulmonary lesions.

METHODS

NAVIGATE is a prospective, multicenter study of the superDimension™ navigation system. A prespecified 1-month interim analysis of the first 1,000 primary cohort subjects enrolled at 29 sites in the United States and Europe is described. Enrollment and 24-month follow-up are ongoing.

RESULTS

ENB index procedures were conducted for lung lesion biopsy (n = 964), fiducial marker placement (n = 210), pleural dye marking (n = 17), and/or lymph node biopsy (n = 334; primarily endobronchial ultrasound-guided). Lesions were in the peripheral/middle lung thirds in 92.7%, 49.7% were <20 mm, and 48.4% had a bronchus sign. Radial EBUS was used in 54.3% (543/1,000 subjects) and general anesthesia in 79.7% (797/1,000). Among the 964 subjects (1,129 lesions) undergoing lung lesion biopsy, navigation was completed and tissue was obtained in 94.4% (910/964). Based on final pathology results, ENB-aided samples were read as malignant in 417/910 (45.8%) subjects and non-malignant in 372/910 (40.9%) subjects. An additional 121/910 (13.3%) were read as inconclusive. One-month follow-up in this interim analysis is not sufficient to calculate the true negative rate or diagnostic yield. Tissue adequacy for genetic testing was 80.0% (56 of 70 lesions sent for testing). The ENB-related pneumothorax rate was 4.9% (49/1,000) overall and 3.2% (32/1,000) CTCAE Grade ≥2 (primary endpoint). The ENB-related Grade ≥2 bronchopulmonary hemorrhage and Grade ≥4 respiratory failure rates were 1.0 and 0.6%, respectively.

CONCLUSIONS

One-month results of the first 1,000 subjects enrolled demonstrate low adverse event rates in a generalizable population across diverse practice settings. Continued enrollment and follow-up are required to calculate the true negative rate and delineate the patient, lesion, and procedural factors contributing to diagnostic yield.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410837 . Registered 31 March 2015.