Electromagnetic navigational bronchoscopy for diagnosing peripheral lung lesions in lung transplant recipients: a single-center experience

[Diagnostic Value and Safety of Electromagnetic Navigation Bronchoscopy in Peripheral Pulmonary Lesions: A Meta-analysis]

BACKGROUND

The incidence and mortality of lung cancer have always been at the forefront of malignant tumors. With the development of lung cancer detection techniques, more peripheral pulmonary lesions (PPLs) have been detected. The diagnostic accuracy of procedures for PPLs keeps controversial. This study aims to systematically evaluate the diagnostic value and the safety of electromagnetic navigation bronchoscopy (ENB) in the diagnosis of PPLs.

METHODS

The relevant literatures in the diagnostic yield of PPLs by ENB were systematically retrieved from Wanfang Data Knowledge Service Platform, China National Knowledge Infrastructure, Embase, PubMed, Cochrane Library and Web of Science. The software of Stata 16.0, RevMan 5.4 and Meta-disc 1.4 were used to conduct the meta-analysis.

RESULTS

A total of 54 literatures with 55 studies were included in our meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of ENB in the diagnosis of PPLs were 0.77 (95%CI: 0.73-0.81), 0.97 (95%CI: 0.93-0.99), 24.27 (95%CI: 10.21-57.67), 0.23 (95%CI: 0.19-0.28) and 104.19 (95%CI: 41.85-259.37), respectively. The area under curve (AUC) was 0.90 (95%CI: 0.87-0.92). Meta-regression and subgroup analyses indicated that the potential heterogeneity resulted from study type, additional localization techniques, sample size, lesion size and type of sedation. The use of additional localization techniques and general anesthesia have improved the diagnostic efficiency of ENB in PPLs. The incidence of adverse reactions and complications associated with ENB was very low.

CONCLUSIONS

ENB provides well diagnostic accuracy and safety.

[Clinical Application of Electromagnetic Navigation Bronchoscopy on the Diagnosis of Peripheral Lung Lesions]

背景与目的

电磁导航支气管镜是一种能够进行肺部病变精准定位的工具，在肺部病变诊断中具有重要价值，但由于价格昂贵，在我国应用尚未普及，急需总结其在临床中的应用，尤其是肺部结节诊断中的经验。

方法

回顾性分析我科2017年7月-2018年12月诊断为肺外周病变，且行电磁导航支气管镜检查患者的临床资料，总结其应用经验。

结果

18例患者（男性10例，女性8例），共21处病变，11例诊断明确，8例诊断为肺腺癌，1例诊断为肺结核，2例诊断为小细胞肺癌，诊断阳性率为61.1%，敏感性为73.3%，诊断阳性率与病变大小相关， > 2 cm病变诊断阳性率为100.0%（P=0.04）。

结论

电磁导航支气管镜在临床中安全有效，对于病变 > 2 cm的肺外周病变诊断阳性率较高，有着广阔的临床应用前景。

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

TRIAL REGISTRY

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

Development of Squamous Cell Carcinoma After Pulmonary Aspergillosis in the Native Lung of a Lung Transplant Recipient: A Case Report

Lung transplant recipients have a significant incidence of posttransplant lung nodules. Such nodules can occur from various etiologies, both in the lung allograft or in the native lung. They most commonly originate from infections, such as Pseudomonas or Aspergillus species, or from posttransplant lymphoproliferative disorder. Lung cancer is challenging to diagnose in a native lung, especially with an underlying fibrotic disease. We present a case of a 75-year-old woman who presented with classic clinical features of pulmonary aspergillosis in the native right lung with idiopathic pulmonary fibrosis 5 years after left-sided single-lung transplant. She required a right lower lobectomy and antifungal treatment with isavuconazonium sulfate and inhaled amphotericin. A persistent right upper lobe lung nodule was noted during surveillance imaging and was initially presumed to be recurrent Aspergillus infection; however, growth of the nodule and change in its characteristics prompted additional examination. A navigational bronchoscopic biopsy was positive for squamous cell carcinoma. Her options for stage IIIA squamous cell carcinoma were limited to chemotherapy with paclitaxel and carboplatin plus radiation. Although initial surveillance scans showed adequate tumor response, metastatic squamous cell carcinoma was found in the liver 6 months later. She was eventually transitioned to palliative care. This case highlights the importance of a high index of suspicion for examination of nodules in the native lung of lung transplant recipients, even in cases of a known diagnosis, owing to the high morbidity and mortality associated with primary lung cancer in this population.