Hierarchical clock-scale hand-drawn mapping as a simple method for bronchoscopic navigation in peripheral pulmonary nodule

A New Approach to Manual CT Scan Reading for Planning the Pathway to Peripheral Pulmonary Lesions

BACKGROUND

Accurate navigation to peripheral pulmonary lesions through bronchoscopy is crucial for lung cancer diagnosis. Manual pathway planning using CT scans can be effective but is often hindered by a steep learning curve and cognitive complexity. Simplifying this process could make manual planning more accessible and reliable, especially when other systems like virtual bronchoscopy (VB) are unavailable or have limitations.In this study, we aimed to evaluate the effectiveness of a simplified manual planning method using multiplanar reconstruction (MPR) compared with VB system for pathway planning to peripheral pulmonary lesions.

METHODS

A retrospective study of 51 CT scans from patients undergoing r-EBUS-guided bronchoscopy was conducted. Pathway planning was performed using VB system (Archimedes) and a simplified manual method leveraging MPR performed by 3 different operators. Concordance between methods and planning times were compared.

RESULTS

Pathway concordance was 78.5% (40/51 cases). The manual method identified additional bifurcations missed by VB in 7 cases and succeeded where VB failed in 3 cases. Mean planning times were 00:45±00:12 for VB and 01:30±00:44 for the manual method (P<0.0001).

CONCLUSION

The simplified manual planning method demonstrated a high level of concordance with VB systems, while offering unique advantages in identifying additional bifurcations and resolving cases where VB systems were unsuccessful. Although the manual method required longer planning times, its cost-effectiveness and accessibility highlight its potential as a valuable alternative, particularly in resource-limited settings or as a tool to enhance bronchoscopists' spatial awareness and procedural confidence.

Automatic lung cancer subtyping using rapid on-site evaluation slides and serum biological markers

BACKGROUND

Rapid on-site evaluation (ROSE) plays an important role during transbronchial sampling, providing an intraoperative cytopathologic evaluation. However, the shortage of cytopathologists limits its wide application. This study aims to develop a deep learning model to automatically analyze ROSE cytological images.

METHODS

The hierarchical multi-label lung cancer subtyping (HMLCS) model that combines whole slide images of ROSE slides and serum biological markers was proposed to discriminate between benign and malignant lesions and recognize different subtypes of lung cancer. A dataset of 811 ROSE slides and paired serum biological markers was retrospectively collected between July 2019 and November 2020, and randomly divided to train, validate, and test the HMLCS model. The area under the curve (AUC) and accuracy were calculated to assess the performance of the model, and Cohen's kappa (κ) was calculated to measure the agreement between the model and the annotation. The HMLCS model was also compared with professional staff.

RESULTS

The HMLCS model achieved AUC values of 0.9540 (95% confidence interval [CI]: 0.9257-0.9823) in malignant/benign classification, 0.9126 (95% CI: 0.8756-0.9365) in malignancy subtyping (non-small cell lung cancer [NSCLC], small cell lung cancer [SCLC], or other malignancies), and 0.9297 (95% CI: 0.9026-0.9603) in NSCLC subtyping (lung adenocarcinoma [LUAD], lung squamous cell carcinoma [LUSC], or NSCLC not otherwise specified [NSCLC-NOS]), respectively. In total, the model achieved an AUC of 0.8721 (95% CI: 0.7714-0.9258) and an accuracy of 0.7184 in the six-class classification task (benign, LUAD, LUSC, NSCLC-NOS, SCLC, or other malignancies). In addition, the model demonstrated a κ value of 0.6183 with the annotation, which was comparable to cytopathologists and superior to trained bronchoscopists and technicians.

CONCLUSION

The HMLCS model showed promising performance in the multiclassification of lung lesions or intrathoracic lymphadenopathy, with potential application to provide real-time feedback regarding preliminary diagnoses of specimens during transbronchial sampling procedures.

CLINICAL TRIAL NUMBER

Not applicable.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Diagnostic outcomes of radial endobronchial ultrasound bronchoscopy guided by manual navigation in the evaluation of peripheral pulmonary lesions: An observational study

BACKGROUND AND AIMS

Manual navigation (MN), drawing a bronchoscopic road map simply by looking at the consecutive computed tomography (CT), is feasible and economical. However, scant data about the use of MN in radial endobronchial ultrasound (r-EBUS) bronchoscopy have been documented till now. We aimed to evaluate the diagnostic performance of r-EBUS bronchoscopy guided by MN for diagnosing peripheral pulmonary lesions (PPLs) and to determine clinical factors affecting the diagnostic yield.

METHODS

We performed a retrospective, cohort study of consecutive patients with PPLs who underwent r-EBUS bronchoscopic biopsy via guidance of MN from May 2020 to June 2021 in our Respiratory Endoscopic Division. The overall diagnostic yield of MN-guided r-EBUS, the factors affecting the yield, and the diagnostic performance for malignancy were evaluated.

RESULTS

A total of 102 patients (103 lesions) were evaluated. The overall diagnostic yield of MN-guided r-EBUS was 82.0%, and it ranged from 79.6% to 82.5%, assuming the undermined cases were all positive cases (79.6%) or negatives (82.5%). The sensitivity of MN-guided r-EBUS for malignancy was 71.4%, ranging from 68.2% to 71.4%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 67.3%, ranging from 63.8% to 69.0%. The multivariate logistic regression showed that "bronchus sign on CT" was the only predictor of the overall diagnostic yield (odds ratio = 11.5, 95% confidence interval: 1.9-70.9, P = 0.009).

CONCLUSIONS

MN-guided r-EBUS is feasible in diagnosing PPLs, especially for lesions with bronchus sign on CT.

Advances in the Treatment of Pulmonary Nodules

BACKGROUND

Early detection and accurate diagnosis of pulmonary nodules are crucial for improving patient outcomes. While surgical resection of malignant nodules is still the preferred treatment option, it may not be feasible for all patients. We aimed to discuss the advances in the treatment of pulmonary nodules, especially stereotactic body radiotherapy (SBRT) and interventional pulmonology technologies, and provide a range of recommendations based on our expertise and experience.

SUMMARY

Interventional pulmonology is an increasingly important approach for the management of pulmonary nodules. While more studies are needed to fully evaluate its long-term outcomes and benefits, the available evidence suggests that this technique can provide a minimally invasive and effective alternative for treating small malignancies in selected patients. We conducted a systematic literature review in PubMed, designed a framework to include the advances in surgery, SBRT, and interventional pulmonology for the treatment of pulmonary nodules, and provided a range of recommendations based on our expertise and experience.

KEY MESSAGES

As such, alternative therapeutic options such as SBRT and ablation are becoming increasingly important and viable. With recent advancements in bronchoscopy techniques, ablation via bronchoscopy has emerged as a promising option for treating pulmonary nodules. This study reviewed the advances of interventional pulmonology in the treatment of peripheral lung cancer patients that are not surgical candidates. We also discussed the challenges and limitations associated with ablation, such as the risk of complications and the potential for incomplete nodule eradication. These advancements hold great promise for improving the efficacy and safety of interventional pulmonology in treating pulmonary nodules.

Ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions

Bronchoscopes are continuously improving. Increasingly, thinner bronchoscopes with larger working channels and better imaging quality are becoming available for clinical use. Concurrently, useful ancillary devices have been developed, such as radial probe endobronchial ultrasound (rEBUS) and navigation devices. Randomized studies have demonstrated the diagnostic superiority of ultrathin bronchoscopy over thin bronchoscopy under rEBUS and virtual bronchoscopic navigation guidance for small, peripheral pulmonary lesions. Furthermore, biopsy needles and cryoprobes have been miniaturized and adapted to the working channel of the new ultrathin bronchoscopes. Multi-modality and multi-instrumental ultrathin bronchoscopy using such new technologies has facilitated high diagnostic yields.

Application of bronchoscopy in the diagnosis and treatment of peripheral pulmonary lesions in China: a national cross-sectional study

Background: Bronchoscopy has gradually become valuable armamentarium in evaluating and applying endoscopic therapy to peripheral pulmonary lesions (PPLs) around the world. We aimed to make a comprehensive understanding of the application of bronchoscopy in the diagnosis and treatment of PPLs in China. Methods: A cross-sectional survey was carried out in China between January 2022 and March 2022. The survey was in the form of an online questionnaire which was filled in with real-time data by the respondents. Results: A total of 347 doctors from 284 tertiary hospitals (81.8%) and 63 secondary general hospitals (18.2%) were included in the data analysis. More than half of the surveyed doctors (55.0%) had independently performed respiratory endoscopy for 5-15 years. Higher proportions of hospitals with a fixed nursing team, anesthesiologists and rapid on-site evaluation (ROSE) during bronchoscopic procedures were performed in tertiary hospitals than those in secondary general hospitals (P<0.001 each). There were 316 hospitals (91.7%) eligible for performing biopsies of PPLs less than 30mm, while more than 300 PPLs biopsies were performed in only 78 hospitals (24.7%) per year. Radial probe endobronchial ultrasound (r-EBUS) (50.3%) was the commonest type of technique used in the guidance of a bronchoscope to PPLs, followed by navigational bronchoscopy (30.3%) and cone beam CT (CBCT) (17.0%). Although two thirds of the surveyed hospitals had at least one bronchoscopic guidance devices, the actual utilization of these devices was not high due to high capital costs and absence of training. To note, more diagnostic procedures and allocated devices were concentrated in the southeast region and coastal cities. Furthermore, therapeutic bronchoscopic interventions for peripheral lung cancer and/or high-risk PPLs could be performed in 124 (35.7%) of the 347 involved hospitals. Conclusions: Bronchoscopy for the diagnosis of PPLs has been carried out in most hospitals in China and yields in different hospitals and regions varied greatly. To date, only a few hospitals in China can develop therapeutic bronchoscopy for PPLs.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.