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Yuan M, Hu Y, Wang L, Yin W, Xiao Y. Diagnostic outcomes of radial endobronchial ultrasound bronchoscopy guided by manual navigation in the evaluation of peripheral pulmonary lesions: An observational study. Clin Respir J 2024; 18:e13768. [PMID: 38685753 PMCID: PMC11058397 DOI: 10.1111/crj.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/02/2024]
Abstract
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.
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Affiliation(s)
- Mingli Yuan
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yi Hu
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Liangchao Wang
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Wen Yin
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yang Xiao
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Bhadra K, Baleeiro C, Patel S, Condra W, Bader BA, Setser RM, Youngblood S. High Tidal Volume, High Positive End Expiratory Pressure and Apneic Breath Hold Strategies (Lung Navigation Ventilation Protocol) With Cone Beam Computed Tomography Bronchoscopic Biopsy of Peripheral Lung Lesions: Results in 100 Patients. J Bronchology Interv Pulmonol 2024; 31:105-116. [PMID: 37459049 PMCID: PMC10984636 DOI: 10.1097/lbr.0000000000000938] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/31/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND A dedicated anesthesia protocol for bronchoscopic lung biopsy-lung navigation ventilation protocol (LNVP)-specifically designed to mitigate atelectasis and reduce unnecessary respiratory motion, has been recently described. LNVP demonstrated significantly reduced dependent ground glass, sublobar/lobar atelectasis, and atelectasis obscuring target lesions compared with conventional ventilation. METHODS In this retrospective, single-center study, we examine the impact of LNVP on 100 consecutive patients during peripheral lung lesion biopsy. We report the incidence of atelectasis using cone beam computed tomography imaging, observed ventilatory findings, anesthesia medications, and outcomes, including diagnostic yield, radiation exposure, and complications. RESULTS Atelectasis was observed in a minority of subjects: ground glass opacity atelectasis was seen in 30 patients by reader 1 (28%) and in 18 patients by reader 2 (17%), with good agreement between readers (κ = 0.78). Sublobar/lobar atelectasis was observed in 23 patients by reader 1 and 26 patients by reader 2, also demonstrating good agreement (κ = 0.67). Atelectasis obscured target lesions in very few cases: 0 patients (0%, reader 1) and 3 patients (3%, reader 2). Diagnostic yield was 85.9% based on the AQuIRE definition. Pathology demonstrated 57 of 106 lesions (54%) were malignant, 34 lesions (32%) were benign, and 15 lesions (14%) were nondiagnostic. CONCLUSION Cone beam computed tomography images confirmed low rates of atelectasis, high tool-in-lesion confirmation rate, and high diagnostic yield. LNVP has a similar safety profile to conventional bronchoscopy. Most patients will require intravenous fluid and vasopressor support. Further study of LNVP and other ventilation protocols are necessary to understand the impact of ventilation protocols on bronchoscopic peripheral lung biopsy.
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Affiliation(s)
| | | | | | | | | | | | - Sloan Youngblood
- American Anesthesia of Tennessee, CHI Memorial Hospital, Chattanooga, TN
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3
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Moulton N, Abbasi M, Ahmad D, Burks A, Chenna P, Haas K, Loiselle A, Mekhaiel E, Pilli S, Sadoughi A, Lydon B, Patel T, Chen AC. Inter- and intra-observer variability of radial-endobronchial ultrasound image interpretation for peripheral pulmonary lesions. J Thorac Dis 2024; 16:450-456. [PMID: 38410559 PMCID: PMC10894385 DOI: 10.21037/jtd-23-998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/24/2023] [Indexed: 02/28/2024]
Abstract
Background Radial probe endobronchial ultrasound (R-EBUS) is often utilized in guided bronchoscopy for the diagnosis of peripheral pulmonary lesions. R-EBUS probe positioning has been shown to correlate with diagnostic yield, but overall diagnostic yield with this technology has been inconsistent across the published literature. Currently there is no standardization for R-EBUS image interpretation, which may result in variability in grading concentricity of lesions and subsequently procedure performance. This was a survey-based study evaluating variability among practicing pulmonologists in R-EBUS image interpretation. Methods R-EBUS images from peripheral bronchoscopy cases were sent to 10 practicing Interventional Pulmonologists at two different time points (baseline and 3 months). Participants were asked to grade the images as concentric, eccentric, or no image. Cohen's Kappa-coefficient was calculated for inter- and intra-observer variability. Results A total of 100 R-EBUS images were included in the survey. There was 100% participation with complete survey responses from all 10 participants. Overall kappa-statistic for inter-observer variability for Survey 1 and 2 was 0.496 and 0.477 respectively. Overall kappa-statistic for intra-observer variability between the two surveys was 0.803. Conclusions There is significant variability between pulmonologists when characterizing R-EBUS images. However, there is strong intra-rater agreement from each participant between surveys. A standardized approach and grading system for radial EBUS patterns may improve inter-observer variability in order to optimize our clinical use and research efforts in the field.
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Affiliation(s)
| | | | | | - Allen Burks
- University of North Carolina, Chapel Hill, NC, USA
| | - Praveen Chenna
- Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Haas
- University of Illinois at Chicago, Chicago, IL, USA
| | - Andrea Loiselle
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | | | - Brandt Lydon
- Washington University School of Medicine, St. Louis, MO, USA
| | - Tej Patel
- Washington University School of Medicine, St. Louis, MO, USA
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Bhadra K, Rickman OB, Mahajan AK, Hogarth DK. "Tool-in-lesion" Accuracy of Galaxy System-A Robotic Electromagnetic Navigation BroncHoscopy With Integrated Tool-in-lesion-Tomosynthesis Technology: The MATCH Study. J Bronchology Interv Pulmonol 2024; 31:23-29. [PMID: 37072895 PMCID: PMC10763708 DOI: 10.1097/lbr.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/21/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The Galaxy System (Noah Medical) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct computerized tomography (CT) to body divergence and novel confirmation of tool-in-lesion (TIL). The primary aim of this study was to assess the TIL accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHODS Four operators conducted the experiment using 4 pigs. Each physician performed between 4 and 6 nodule biopsies for 20 simulated lung nodules with purple dye and a radio pacifier. Using Galaxy's "Tool-in-Lesion Tomography (TOMO+)" with augmented fluoroscopy, the physician navigated to the lung nodules, and a tool (needle) was placed into the lesion. TIL was defined by the needle in the lesion determined by cone-beam CT. RESULTS The lung nodule's average size was 16.3 ± 0.97 mm and was predominantly in the lower lobes (65%). All 4 operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). TIL after the final TOMO sweep was 95% (19/20) and tool-touch-lesion was 5% (1/20). Biopsy yielding purple pigmentation was also 100% (20/20). CONCLUSION The Galaxy System demonstrated successful digital TOMO confirmed TIL success in 95% (19/20) of lesions and tool-touch-lesion in 5% (1/20) as confirmed by cone-beam CT. Successful diagnostic yield was achieved in 100% (20/20) of lesions as confirmed by intralesional pigment acquisition.
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Affiliation(s)
- Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga
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Ali MS, Ghori UK, Wayne MT, Shostak E, De Cardenas J. Diagnostic Performance and Safety Profile of Robotic-assisted Bronchoscopy: A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2023; 20:1801-1812. [PMID: 37769170 DOI: 10.1513/annalsats.202301-075oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/27/2023] [Indexed: 09/30/2023] Open
Abstract
Rationale: Conventional electromagnetic navigation bronchoscopy and other guided bronchoscopic modalities have a very desirable safety profile, but their diagnostic yield is only 60-70% for pulmonary lesions. Recently, robotic-assisted bronchoscopy (RAB) platforms have been introduced to improve the diagnostic performance of bronchoscopic modalities. Objectives: To determine the diagnostic performance and safety profile of RAB (using shape-sensing and electromagnetic navigation-based platforms) by performing a systematic review and meta-analysis. Methods: The PubMed, Embase, and Google Scholar databases were searched to find studies that reported on the diagnostic performance and/or the safety profile of one of the RAB systems. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was performed using MedCalc version 20.118. Pooled diagnostic yield was calculated using a Freeman-Tukey transformation. We planned to use a random-effects model if the I2 index was >40%. Results: Twenty-five studies were included: 20 including diagnostic and safety analyses and 5 including only safety analyses. The pooled diagnostic yield of RAB (20 studies, 1,779 lesions) was 84.3% (95% confidence interval, 81.1-87.2%). The I2 index was 65.6%. On the basis of our subgroup analyses, the heterogeneity was likely driven by differences in study designs (prospective vs. retrospective) and procedural protocols (such as different RAB systems). Lesion size > 2 cm, the presence of a computed tomography bronchus sign, and concentric radial endobronchial ultrasound view were associated with a statistically significant increase in the odds of diagnosis with RAB. The overall rates of pneumothorax, need for tube thoracostomy, and significant hemorrhage were 2.3%, 1.2%, and 0.5%, respectively. Conclusions: RAB systems have significantly increased the diagnostic yield of navigational bronchoscopy compared with conventional systems such as electromagnetic navigation bronchoscopy, but well-designed prospective studies are needed to better understand the impact of various factors, such as the use of three-dimensional imaging modalities, cryobiopsy, and specific ventilatory protocols, on the diagnostic yield of RAB.
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Affiliation(s)
- Muhammad Sajawal Ali
- Division of Pulmonary and Critical Care Medicine
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Uzair Khan Ghori
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Max Theodore Wayne
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Eugene Shostak
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Jose De Cardenas
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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DiBardino DM, Kim RY, Cao Y, Andronov M, Lanfranco AR, Haas AR, Vachani A, Ma KC, Hutchinson CT. Diagnostic Yield of Cone-beam-Derived Augmented Fluoroscopy and Ultrathin Bronchoscopy Versus Conventional Navigational Bronchoscopy Techniques. J Bronchology Interv Pulmonol 2023; 30:335-345. [PMID: 35920067 PMCID: PMC10538603 DOI: 10.1097/lbr.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pulmonary nodules suspicious for lung cancer are frequently diagnosed. Evaluating and optimizing the diagnostic yield of lung nodule biopsy is critical as innovation in bronchoscopy continues to progress. METHODS This is a retrospective cohort study. Consecutive patients undergoing guided bronchoscopy for suspicious pulmonary nodule(s) between February 2020 and July 2021 were included. The cone-beam computed tomography (CBCT)+ radial endobronchial ultrasound (r-EBUS) group had their procedure using CBCT-derived augmented fluoroscopy along with r-EBUS. The CBCT+ ultrathin bronchoscope (UTB)+r-EBUS group had the same procedure but with the use of an ultrathin bronchoscope. The r-EBUS group underwent r-EBUS guidance without CBCT or augmented fluoroscopy. We used multivariable logistic regression to compare diagnostic yield, adjusting for confounding variables. RESULTS A total of 116 patients were included. The median pulmonary lesion diameter was 19.5 mm (interquartile range, 15.0 to 27.5 mm), and 91 (78.4%) were in the peripheral half of the lung. Thirty patients (25.9%) underwent CBCT+UTB, 27 (23.3%) CBCT, and 59 (50.9%) r-EBUS alone with unadjusted diagnostic yields of 86.7%, 70.4%, and 42.4%, respectively ( P <0.001). The adjusted diagnostic yields were 85.0% (95% CI, 68.6% to 100%), 68.3% (95% CI, 50.1% to 86.6%), and 44.5% (95% CI, 31.0% to 58.0%), respectively. There was significantly more virtual navigational bronchoscopy use in the r-EBUS group (45.8%) compared with the CBCT+UTB (13.3%) and CBCT (18.5%) groups, respectively. CBCT procedures required dose area product radiation doses of 7602.5 µGym 2 . CONCLUSION Compared with the r-EBUS group, CBCT + UTB + r-EBUS was associated with higher navigational success, fewer nondiagnostic biopsy results, and a higher diagnostic yield. CBCT procedures are associated with a considerable radiation dose.
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Affiliation(s)
- David M. DiBardino
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Yulei Cao
- Drexel University College of Medicine, Philadelphia, PA
| | - Michelle Andronov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Anthony R. Lanfranco
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Andrew R. Haas
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Kevin C. Ma
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Christoph T. Hutchinson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
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Styrvoky K, Schwalk A, Pham D, Madsen K, Chiu HT, Abu-Hijleh M. Radiation dose of cone beam CT combined with shape sensing robotic assisted bronchoscopy for the evaluation of pulmonary lesions: an observational single center study. J Thorac Dis 2023; 15:4836-4848. [PMID: 37868864 PMCID: PMC10586938 DOI: 10.21037/jtd-23-587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/18/2023] [Indexed: 10/24/2023]
Abstract
Background Shape sensing robotic-assisted bronchoscopy (ssRAB) combined with radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography (CBCT) is a newer diagnostic modality for the evaluation of pulmonary lesions. There is limited data describing the radiation dose of CBCT combined with ssRAB. The purpose of this study was to describe the technical factors associated with the use of CBCT combined with ssRAB to biopsy pulmonary lesions. Methods We conducted a single center, prospective observational study of patients undergoing ssRAB combined with fixed CBCT for the pulmonary lesion biopsy. We report our patient demographics, and pulmonary lesion and procedure characteristics. Results A total of 241 ssRAB procedures were performed to biopsy 269 pulmonary lesions. The mean lesion size was measured in the following dimensions: anteroposterior (18.0±8.8 mm), transverse (17.2±10.5 mm), and craniocaudal (17.7±10.2 mm). A mean of 1.5±0.7 (median: 1, range: 1-4) CBCT spins were performed. The mean total fluoroscopy time (FT) was 5.6±2.9 minutes. The mean radiation dose of cumulative air kerma (CAK) was 63.5±46.7 mGy and the mean cumulative dose area product (DAP) was 22.6±16.0 Gy·cm2. Diagnostic yield calculated based on results at index bronchoscopy was 85.9%. There was a low rate of complications with 8 pneumothoraces (3.3%), 5 (2.1%) of which required chest tube placement. Conclusions We describe the use of ssRAB combined with CBCT to biopsy pulmonary lesions as a safe diagnostic modality with relatively low radiation dose that is potentially comparable to other image guided sampling modalities. Bronchoscopists should be cognizant of the radiation use during the procedure for both patient and staff safety.
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Affiliation(s)
- Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Audra Schwalk
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Pham
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristine Madsen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hsienchang T. Chiu
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Muhanned Abu-Hijleh
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ortiz-Jaimes G, Reisenauer J. Real-World Impact of Robotic-Assisted Bronchoscopy on the Staging and Diagnosis of Lung Cancer: The Shape of Current and Potential Opportunities. Pragmat Obs Res 2023; 14:75-94. [PMID: 37694262 PMCID: PMC10492559 DOI: 10.2147/por.s395806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
The approach to peripheral pulmonary lesions (PPL) has been evolving continuously. Advanced bronchoscopic navigational techniques have improved the airway-based approaches to these lesions. Robotic Assisted Bronchoscopy (RAB) can be considered the current pinnacle of this evolution; allowing for a safer approach to sampling lesions previously considered outside of bronchoscopic reach. We present a comprehensive review of the changing epidemiology of lung cancer and the importance of early tissue sampling, the evolution of sampling and navigational bronchoscopic techniques, technical considerations and evidence pertaining to the use of RAB, and adjunct techniques in the diagnosis of lung cancer. Complications and future applications of RAB are also discussed.
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Affiliation(s)
- Gabriel Ortiz-Jaimes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
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Ho E, Hedstrom G, Murgu S. Robotic bronchoscopy in diagnosing lung cancer-the evidence, tips and tricks: a clinical practice review. Ann Transl Med 2023; 11:359. [PMID: 37675302 PMCID: PMC10477625 DOI: 10.21037/atm-22-3078] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 12/09/2022] [Indexed: 09/08/2023]
Abstract
The development of robotic-assisted bronchoscopy has empowered bronchoscopists to access the periphery of the lung with more confidence and promising accuracy. This is due in large to the superior maneuverability, further reach, and stability of these technologies. Despite the advantages of robotic bronchoscopy, there are some drawbacks to using these technologies, such as the loss of tactile feedback, the need to overcome computed tomography (CT)-to-body divergence, and the potential for overreliance on the navigation software. There are currently two robotic bronchoscopy platforms on the US market, the MonarchTM Platform by Auris Health© (Redwood City, CA, USA) and the IonTM endoluminal robotic bronchoscopy platform by Intuitive Surgical© (Sunnyvale, CA, USA). In this clinical practice review, we highlight the evidence and strategies for successful clinical use of both robotic bronchoscopy platforms for pulmonary lesion sampling. Specifically, we will review pre-procedural considerations, such as procedural mapping, room set-up and anesthesia considerations. We will also review the technical aspects of using the robotic bronchoscopy platforms, such as how to compensate for the loss of tactile feedback, optimize visualization, use of ancillary technology to accommodate for CT-to-body divergence, employ best practices for sampling techniques, and utilize information from rapid on-site evaluation (ROSE) to aid in improving diagnostic yield.
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Affiliation(s)
- Elliot Ho
- Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Grady Hedstrom
- Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Septimiu Murgu
- Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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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: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Huang H, Wu N, Tian S, Shi D, Wang C, Wang G, Jin F, Li S, Dong Y, Simoff MJ, Li Q, Bai C. Application of bronchoscopy in the diagnosis and treatment of peripheral pulmonary lesions in China: a national cross-sectional study. J Cancer 2023; 14:1398-1406. [PMID: 37283786 PMCID: PMC10240658 DOI: 10.7150/jca.84220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/06/2023] [Indexed: 06/08/2023] Open
Abstract
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.
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Affiliation(s)
- Haidong Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ning Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Sen Tian
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Dongchen Shi
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Changhui Wang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Faguang Jin
- Department of Respiratory and Critical Care Medicine, Tangdu Hospital, Air Force Military Medical University, Xian, China
| | - Shiyue Li
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuchao Dong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Michael J Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Qiang Li
- Department of Pulmonary and Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chong Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
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12
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Beltran Ale G, Simpson R, Mertens C, Santillana E, Hill B, Carlo WF, Batra H. Shape-sensing robotic bronchoscopy in the diagnosis of pulmonary lesions in children. Pediatr Pulmonol 2023; 58:1607-1609. [PMID: 36718986 DOI: 10.1002/ppul.26341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Guillermo Beltran Ale
- Division of Pediatric Pulmonary and Sleep Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryne Simpson
- Division of Pediatric Pulmonary and Sleep Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christopher Mertens
- Division of Pediatric Pulmonary and Sleep Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elsa Santillana
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Hill
- Department of Pathology, Children's of Alabama, Birmingham, Alabama, USA
| | - Waldemar F Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hitesh Batra
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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13
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Chambers J, Knox D, Leclair T. O-arm CT for Confirmation of Successful Navigation During Robotic Assisted Bronchoscopy. J Bronchology Interv Pulmonol 2023; 30:155-162. [PMID: 36066326 PMCID: PMC10063183 DOI: 10.1097/lbr.0000000000000894] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Robotic assisted bronchoscopy (RAB) is designed to increase bronchoscopic accessibility for difficult to reach pulmonary lesions. One limitation to success of RAB is computed tomography (CT) to body divergence. Real time imaging with cone beam CT is increasingly utilized for confirmation of correct navigation and tool-in-lesion during RAB. O-arm CT is a 3-dimensional imaging modality, which has not previously been described for use with RAB. Our purpose is to display the feasibility, ease of use, and high rate of confirmation of tool-in-lesion when using O-arm CT during RAB. METHODS Single center, retrospective review of 75 patients undergoing RAB with intraprocedural use of O-arm CT. RESULTS Median patient age was 65 years. Forty-nine percent of cases involved nodules ≤2 cm. Bronchus sign was absent in 44% of cases. Median procedure time was 80 minutes. Median number of O-arm CT runs per case was 2. The median effective dose of radiation was 7.2 millisieverts. Tool-in-lesion was confirmed in 97% (77 of 79) of cases. Definitive diagnosis was reached in 61 to 68 of 79 cases (77% to 86%). There were 2 cases of pneumothorax (2.5%), one of which needed intervention with tube thoracostomy. CONCLUSIONS O-arm CT is an effective, and convenient alternative to other 3-dimensional imaging modalities for intraprocedural confirmation of tool-in-lesion during RAB.
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Affiliation(s)
- Jefferson Chambers
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Daniel Knox
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Timothy Leclair
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
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14
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Duke JD, Reisenauer J. Robotic bronchoscopy: potential in diagnosing and treating lung cancer. Expert Rev Respir Med 2023; 17:213-221. [PMID: 36939545 DOI: 10.1080/17476348.2023.2192929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Lung cancer remains the deadliest form of cancer in the world. Screening through low-dose CT scans has shown improved detection of pulmonary nodules; however, with the introduction of robotic bronchoscopy, accessing and biopsying peripheral pulmonary nodules from the airway has expanded. Improved diagnostic yield through enhanced navigation has made robotic bronchoscopy an ideal diagnostic technology for many proceduralists. Studies have demonstrated that robotic bronchoscopes can reach further with improved maneuverability into the distal airways compared to conventional bronchoscopes. AREAS COVERED This review paper highlights the literature on the technological advancements associated with robotic bronchoscopy and the future directions the field of interventional pulmonary may utilize this modality for in the treatment of lung cancer. Referenced articles were included at the discretion of the authors after a database search of the particular technology discussed. EXPERT OPINION As the localization of target lesions continues to improve, robotic platforms that provide reach, stability, and accuracy paves the way for future research in endoluminal treatment for lung cancer. Future studies with intratumoral injection of chemotherapy and immunotherapy and ablation modalities are likely to come in the coming years.
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Affiliation(s)
- Jennifer D Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic Rochester, Rochester, MN, USA
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15
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Ravikumar N, Ho E, Wagh A, Murgu S. Advanced Imaging for Robotic Bronchoscopy: A Review. Diagnostics (Basel) 2023; 13. [PMID: 36900134 DOI: 10.3390/diagnostics13050990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Recent advances in navigational platforms have led bronchoscopists to make major strides in diagnostic interventions for pulmonary parenchymal lesions. Over the last decade, multiple platforms including electromagnetic navigation and robotic bronchoscopy have allowed bronchoscopists to safely navigate farther into the lung parenchyma with increased stability and accuracy. Limitations persist, even with these newer technologies, in achieving a similar or higher diagnostic yield when compared to the transthoracic computed tomography (CT) guided needle approach. One of the major limitations to this effect is due to CT-to-body divergence. Real-time feedback that better defines the tool-lesion relationship is vital and can be obtained with additional imaging using radial endobronchial ultrasound, C-arm based tomosynthesis, cone-beam CT (fixed or mobile), and O-arm CT. Herein, we describe the role of this adjunct imaging with robotic bronchoscopy for diagnostic purposes, describe potential strategies to counteract the CT-to-body divergence phenomenon, and address the potential role of advanced imaging for lung tumor ablation.
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16
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Freyaldenhoven ST, Tsukada H. Robotics in the diagnosis and staging of lung cancer. J Surg Oncol 2023; 127:258-261. [PMID: 36630090 DOI: 10.1002/jso.27189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023]
Abstract
The diagnosis of peripheral small lung lesions by electromagnetic navigational bronchoscopy is still inferior to computed tomography (CT) guided percutaneous transthoracic needle lung biopsy. Robotic bronchoscopy is a new technology that may be a potential breakthrough in the diagnosis of small lung lesions. Real-time tools such as electromagnetic navigation, radial-endobronchial ultrasound, and cone beam CT may further improve the diagnostic yield rate may further improve the diagnostic yield rate. In this article, we reviewed early experience of robotic bronchoscopy for diagnosis and staging of lung cancer.
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Affiliation(s)
- Samuel T Freyaldenhoven
- Department of Surgery, Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hisashi Tsukada
- Department of Surgery, Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Diddams MJ, Lee HJ. Robotic Bronchoscopy: Review of Three Systems. Life (Basel) 2023; 13. [PMID: 36836710 DOI: 10.3390/life13020354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/31/2023] Open
Abstract
Robotic bronchoscopy (RB) has been shown to improve access to smaller and more peripheral lung lesions, while simultaneously staging the mediastinum. Pre-clinical studies demonstrated extremely high diagnostic yields, but real-world RB yields have yet to fully matched up in prospective studies. Despite this, RB technology has rapidly evolved and has great potential for lung-cancer diagnosis and even treatment. In this article, we review the historical and present challenges with RB in order to compare three RB systems.
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18
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Dunn BK, Blaj M, Stahl J, Speicher J, Anciano C, Hudson S, Kragel EA, Bowling MR. Evaluation of Electromagnetic Navigational Bronchoscopy Using Tomosynthesis-Assisted Visualization, Intraprocedural Positional Correction and Continuous Guidance for Evaluation of Peripheral Pulmonary Nodules. J Bronchology Interv Pulmonol 2023; 30:16-23. [PMID: 35271510 PMCID: PMC9803388 DOI: 10.1097/lbr.0000000000000839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 02/01/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Electromagnetic navigational bronchoscopy (ENB) has been shown to have variable diagnostic accuracy for the assessment of peripheral pulmonary nodules. This may be because of discrepancies between the preplanned computed tomography of chest target lesion location versus actual target location (computed tomography-to-body divergence), and the lack of a continuous navigational image. The ILLUMISITE (Medtronic, Minneapolis, MN) is a newly developed ENB platform that utilizes tomosynthesis, an imaging technology that can visualize the target location using fluoroscopy (F-ENB). This new system also allows for intraprocedural positional correction and continuous navigation guidance during sampling to overcome these limitations and improve diagnostic yield. We report our first experience in a single center, single proceduralist using this new technology. METHODS We conducted a retrospective, single center, single operator study reviewing 72 consecutive patients (78 nodules) over a 3-month period. We investigated the overall diagnostic yield and diagnostic yield by nodule location, size, and sedation type using this new F-ENB system. RESULTS The overall diagnostic yield was 87% and pnemothoraces occurred in 2/78 procedures. We did not find any statistically significant difference when comparing pulmonary nodule location, size or sedation method utilized ( P =0.231, 0.338, and 0.112, respectively). Sixty-nine percent of the pulmonary nodules biopsied were 2 to 3 cm in size. The average distance corrected after tomosynthesis visualization was 15.4 mm (0.4 to 29.8 mm). CONCLUSION We report our initial experience with the ILLUMISITE system using fluoroscopic tomosynthesis-assisted visualization with continuous navigational guidance at our institution. This new technology allows the operator to correct for better target lesion alignment and real time positional correction and may improve diagnostic yields with minimal complications for evaluation of peripheral pulmonary nodules.
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Affiliation(s)
- Bryan K. Dunn
- Division of Pulmonary, Brody School of Medicine, Critical Care, and Sleep Medicine
| | - Michael Blaj
- Division of Pulmonary, Brody School of Medicine, Critical Care, and Sleep Medicine
| | - Jennifer Stahl
- Division of Pulmonary, Brody School of Medicine, Critical Care and Emergency Medicine
| | - James Speicher
- Division of Thoracic and Foregut Surgery, Department of Cardiovascular Sciences, Brody School of Medicine
| | - Carlos Anciano
- Division of Thoracic and Foregut Surgery, Department of Cardiovascular Sciences, Brody School of Medicine
| | - Suzanne Hudson
- Department of Biostatistics, East Carolina University, Greenville, NC
| | - Emily A. Kragel
- Division of Pulmonary, Brody School of Medicine, Critical Care, and Sleep Medicine
| | - Mark R. Bowling
- Division of Pulmonary, Brody School of Medicine, Critical Care, Sleep Medicine, and Oncology
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19
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Duke JD, Sanborn D, Reisenauer J. Enhancing Nodule Biopsy Through Technology Integration. Innovations (Phila) 2023; 18:103-105. [PMID: 36800897 DOI: 10.1177/15569845231153639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Technology in navigating to peripheral pulmonary nodules has improved in recent years. The recent integration of a robotic platform using shape-sensing technology and mobile cone-beam computed tomography imaging technology has enhanced confidence in sampling lesions with intraprocedural imaging by complimenting the pre-planned navigation to peripheral pulmonary nodules. We present 2 cases using the software integration that improved the robotic catheter positioning to allow for diagnostic specimens to be obtained in the initial biopsies.
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Affiliation(s)
- Jennifer D Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Sanborn
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
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20
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Ho E, Cho RJ, Keenan JC, Murgu S. The Feasibility of Using the "Artery Sign" for Pre-Procedural Planning in Navigational Bronchoscopy for Parenchymal Pulmonary Lesion Sampling. Diagnostics (Basel) 2022; 12. [PMID: 36553068 DOI: 10.3390/diagnostics12123059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) and robotic-assisted bronchoscopy (RAB) systems are used for pulmonary lesion sampling, and utilize a pre-procedural CT scan where an airway, or "bronchus sign", is used to map a pathway to the target lesion. However, up to 40% of pre-procedural CT's lack a "bronchus sign" partially due to surrounding emphysema or limitation in CT resolution. Recognizing that the branches of the pulmonary artery, lymphatics, and airways are often present together as the bronchovascular bundle, we postulate that a branch of the pulmonary artery ("artery sign") could be used for pathway mapping during navigation bronchoscopy when a "bronchus sign" is absent. Herein we describe the navigation success and safety of using the "artery sign" to create a pathway for pulmonary lesion sampling. METHODS We reviewed data on consecutive cases in which the "artery sign" was used for pre-procedural planning for conventional ENB (superDimension™, Medtronic) and RAB (Monarch™, Johnson & Johnson). Patients who underwent these procedures from July 2020 until July 2021 at the University of Minnesota Medical Center and from June 2018 until December 2019 at the University of Chicago Medical Center were included in this analysis (IRB #19-0011 for the University of Chicago and IRB #00013135 for the University of Minnesota). The primary outcome was navigation success, defined as successfully maneuvering the bronchoscope to the target lesion based on feedback from the navigation system. Secondary outcomes included navigation success based on radial EBUS imaging, pneumothorax, and bleeding rates. RESULTS A total of 30 patients were enrolled in this analysis. The median diameter of the lesions was 17 mm. The median distance of the lesion from the pleura was 5 mm. Eleven lesions were solid, 15 were pure ground glass, and 4 were mixed. All cases were planned successfully using the "artery sign" on either the superDimension™ ENB (n = 15) or the Monarch™ RAB (n = 15). Navigation to the target was successful for 29 lesions (96.7%) based on feedback from the navigation system (virtual target). Radial EBUS image was acquired in 27 cases (90%) [eccentric view in 13 (43.33%) and concentric view in 14 patients (46.66%)], while in 3 cases (10%) no r-EBUS view was obtained. Pneumothorax occurred in one case (3%). Significant airway bleeding was reported in one case (3%). CONCLUSIONS We describe the concept of using the "artery sign" as an alternative for planning EMN and RAB procedures when "bronchus sign" is absent. The navigation success based on virtual target or r-EBUS imaging is high and safety of sampling of such lesions compares favorably with prior reports. Prospective studies are needed to assess the impact of the "artery sign" on diagnostic yield.
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21
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Pittiglio G, Lloyd P, da Veiga T, Onaizah O, Pompili C, Chandler JH, Valdastri P. Patient-Specific Magnetic Catheters for Atraumatic Autonomous Endoscopy. Soft Robot 2022; 9:1120-1133. [PMID: 35312350 PMCID: PMC9805888 DOI: 10.1089/soro.2021.0090] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite increasing interest in minimally invasive surgical techniques and related developments in flexible endoscopes and catheters, follow-the-leader motion remains elusive. Following the path of least resistance through a tortuous and potentially delicate environment without relying on interaction with the surrounding anatomy requires the control of many degrees of freedom. This typically results in large-diameter instruments. One viable solution to obtain dexterity without increasing size is via multiple-point magnetic actuation over the length of the catheter. The main challenge of this approach is planning magnetic interaction to allow the catheter to adapt to the surrounding anatomy during navigation. We design and manufacture a fully shape-forming, soft magnetic catheter of 80 mm length and 2 mm diameter, capable of navigating a human anatomy in a follow-the-leader fashion. Although this system could be exploited for a range of endoscopic or intravascular applications, here we demonstrate its efficacy for navigational bronchoscopy. From a patient-specific preoperative scan, we optimize the catheters' magnetization profiles and the shape-forming actuating field. To generate the required transient magnetic fields, a dual-robot arm system is employed. We fabricate three separate prototypes to demonstrate minimal contact navigation through a three-dimensional bronchial tree phantom under precomputed robotic control. We also compare a further four separate optimally designed catheters against mechanically equivalent designs with axial magnetization profiles along their length and only at the tip. Using our follow-the-leader approach, we demonstrate up to 50% more accurate tracking, 50% reduction in obstacle contact time during navigation over the state of the art, and an improvement in targeting error of 90%.
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Affiliation(s)
- Giovanni Pittiglio
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Peter Lloyd
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Tomas da Veiga
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Onaizah Onaizah
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Cecilia Pompili
- Leeds Institute of Medical Research (LIMR), University of Leeds, Leeds, United Kingdom
| | - James H. Chandler
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Pietro Valdastri
- STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom.,Address correspondence to: Pietro Valdastri, STORM Lab, School of Electronic and Electrical Engineering, University of Leeds, Woodhouse, LS2 9JT Leeds, United Kingdom
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Stone E, Leong TL. Contemporary Concise Review 2021: Pulmonary nodules from detection to intervention. Respirology 2022; 27:776-785. [PMID: 35581532 DOI: 10.1111/resp.14296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 12/11/2022]
Abstract
The US Preventive Task Force (USPSTF) has updated screening criteria by expanding age range and reducing smoking history required for eligibility; the International Lung Screen Trial (ILST) data have shown that PLCOM2012 performs better for eligibility than USPSTF criteria. Screening adherence is low (4%-6% of potential eligible candidates in the United States) and depends upon multiple system and patient/candidate-related factors. Smoking cessation in lung cancer improves survival (past prospective trial data, updated meta-analysis data); smoking cessation is an essential component of lung cancer screening. Circulating biomarkers are emerging to optimize screening and early diagnosis. COVID-19 continues to affect lung cancer treatment and screening through delays and disruptions; specific operational challenges need to be met. Over 70% of suspected malignant lesions develop in the periphery of the lungs. Bronchoscopic navigational techniques have been steadily improving to allow greater accuracy with target lesion approximation and therefore diagnostic yield. Fibre-based imaging techniques provide real-time microscopic tumour visualization, with potential diagnostic benefits. With significant advances in peripheral lung cancer localization, bronchoscopically delivered ablative therapies are an emerging field in limited stage primary and oligometastatic disease. In advanced stage lung cancer, small-volume samples acquired through bronchoscopic techniques yield material of sufficient quantity and quality to support clinically relevant biomarker assessment.
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Affiliation(s)
- Emily Stone
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tracy L Leong
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Levine MZ, Goodman S, Lentz RJ, Maldonado F, Rickman OB, Katsis J. Advanced Bronchoscopic Technologies for Biopsy of the Pulmonary Nodule: A 2021 Review. Diagnostics (Basel) 2021; 11:2304. [PMID: 34943541 DOI: 10.3390/diagnostics11122304] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/23/2021] [Accepted: 12/05/2021] [Indexed: 12/26/2022] Open
Abstract
The field of interventional pulmonology (IP) has grown from a fringe subspecialty utilized in only a few centers worldwide to a standard component in advanced medical centers. IP is increasingly recognized for its value in patient care and its ability to deliver minimally invasive and cost-effective diagnostics and treatments. This article will provide an in-depth review of advanced bronchoscopic technologies used by IP physicians focusing on pulmonary nodules. While most pulmonary nodules are benign, malignant nodules represent the earliest detectable manifestation of lung cancer. Lung cancer is the second most common and the deadliest cancer worldwide. Differentiating benign from malignant nodules is clinically challenging as these entities are often indistinguishable radiographically. Tissue biopsy is often required to discriminate benign from malignant nodule etiologies. A safe and accurate means of definitively differentiating benign from malignant nodules would be highly valuable for patients, and the medical system at large. This would translate into a greater number of early-stage cancer detections while reducing the burden of surgical resections for benign disease. There is little high-grade evidence to guide clinicians on optimal lung nodule tissue sampling modalities. The number of novel technologies available for this purpose has rapidly expanded over the last decade, making it difficult for clinicians to assess their efficacy. Unfortunately, there is a wide variety of methods used to determine the accuracy of these technologies, making comparisons across studies impossible. This paper will provide an in-depth review of available data regarding advanced bronchoscopic technologies.
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Ekeke CN, Vercauteren M, Istvaniczdravkovic S, Semaan R, Dhupar R. Lung Nodule Evaluation Using Robotic-Assisted Bronchoscopy at a Veteran's Affairs Hospital. J Clin Med 2021; 10:3671. [PMID: 34441966 DOI: 10.3390/jcm10163671] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 01/05/2023] Open
Abstract
The incidence of lung nodules has increased with improved diagnostic imaging and screening protocols. Despite improvements for diagnosing pulmonary nodules with technologies such as electromagnetic navigational bronchoscopy (ENB), several limitations still exist including adequate visualization, localization, and diagnostic yield. Robotic-assisted bronchoscopy with ENB has been introduced as a method to overcome these shortcomings. We describe our initial experience in evaluating lung nodules with robotic assisted bronchoscopy. We retrospectively reviewed data on the first 25 patients that underwent robotic-assisted bronchoscopy and biopsy. We analyzed success with localization, diagnostic yield, and post procedural morbidity. Diagnostic yield was 96% (24/25) with no periprocedural morbidity. The majority of nodules were malignant or atypical (76%) and were located in the right upper lobe. Diameter ranged between 0.8–6.9 cm (median size 1–2 cm). Seventy-five percent of patients underwent subsequent treatment for cancer based on these results, with 25% having continued surveillance. Robotic assisted bronchoscopy is safe and accurate. Studies with larger numbers will allow better understanding of the diagnostic yield and clinical utility of this approach in comparison to other diagnostic tools for lung nodules.
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Lat T, Sanchez JF, McGraw MK, Hodjat P, White HD, Boethel CD. Decision-making in diagnosis of bronchus-associated lymphoid tissue lymphoma. Proc (Bayl Univ Med Cent) 2021; 34:451-455. [PMID: 34219924 DOI: 10.1080/08998280.2021.1889275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Bronchus-associated lymphoid tissue (BALT) lymphomas of the lung are uncommon, and diagnosis is often delayed due to the indolent clinical course. Often, adequate samples are difficult to obtain by bronchoscopy with transbronchial biopsy alone. This retrospective study reviewed the diagnosis and treatment of BALT lymphoma cases at our institution over the course of 19 years. Most patients were white, women, and >50 years old; the mean Charlson Comorbidity Index at the time of diagnosis was 6. Seven of 12 patients presented with solitary nodules or multiple nodules. For six cases, initial modalities were nondiagnostic; four subsequently underwent surgical biopsy, one underwent computed tomography-guided biopsy, and one underwent navigational bronchoscopy for final diagnosis of BALT lymphoma. Ultimately, 55% of cases were diagnosed with nonsurgical biopsy. One patient suffered a pneumothorax related to the initial diagnostic attempt. Ten patients received chemotherapy, radiation, and/or surgery, and 11 of the 12 are still alive. Our data confirm the previously described indolent behavior of BALT lymphomas and the challenges related to diagnosis. While previous studies have suggested surgical biopsy as the primary modality for obtaining histopathology, navigational bronchoscopy could serve as a safer alternative.
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Affiliation(s)
- Tasnim Lat
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, Texas
| | - Juan F Sanchez
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, Texas
| | - Meghan K McGraw
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, Texas
| | - Parsa Hodjat
- Department of Pathology, Baylor Scott & White Health, Temple, Texas
| | - Heath D White
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, Texas
| | - Carl D Boethel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, Texas
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Desai NR, Gildea TR, Kessler E, Ninan N, French KD, Merlino DA, Wahidi MM, Kovitz KL. Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement. Chest 2021; 160:259-267. [PMID: 33581100 DOI: 10.1016/j.chest.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022] Open
Abstract
Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.
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Affiliation(s)
- Neeraj R Desai
- Chicago Chest Center, University of Illinois at Chicago, Chicago; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago; AMITA Health, Lisle, IL.
| | | | - Edward Kessler
- Chicago Chest Center, University of Illinois at Chicago, Chicago; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago; AMITA Health, Lisle, IL
| | | | - Kim D French
- Chicago Chest Center, University of Illinois at Chicago, Chicago; AMITA Health, Lisle, IL
| | - Denise A Merlino
- Merlino Healthcare Consulting Corp. (D. A. Merlino), Gloucester, PA, Durham, NC
| | | | - Kevin L Kovitz
- Chicago Chest Center, University of Illinois at Chicago, Chicago; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago; AMITA Health, Lisle, IL
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Kho SS, Nyanti LE, Chai CS, Chan SK, Tie ST. Feasibility of manual bronchial branch reading technique in navigating conventional rEBUS bronchoscopy in the evaluation of peripheral pulmonary lesion. Clin Respir J 2020; 15:595-603. [PMID: 33113256 DOI: 10.1111/crj.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/09/2020] [Accepted: 10/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although radial endobronchial ultrasound (rEBUS) is an important verification tool in guided bronchoscopy, a navigational route was not provided. Manual airway mapping allows the bronchoscopist to translate the bronchial branching in computed tomography (CT) into a comparable bronchoscopic road map. We aimed to explore the feasibility of this technique in navigating conventional rEBUS bronchoscopy in the localisation of peripheral pulmonary lesion by determining navigation success and diagnostic yield. METHODS Retrospective review of consecutive rEBUS bronchoscopy performed with a 6.2 mm conventional bronchoscope navigated via manual bronchial branch reading technique over 18 months. RESULTS Ninety-eight target lesions were included. Median lesion size was 2.67 cm (IQR 2.22-3.38) with 96.9% demonstrating positive CT bronchus sign. Majority (86.7%) of lesions were situated in between the third and fifth airway generations. Procedure was performed with endotracheal intubation in 43.9% and fluoroscopy in 72.4%. 98.9% of lesions were successfully navigated and verified by rEBUS following the pre-planned airway road map. Bidirectional guiding device was employed in 29.6% of cases. Clinical diagnosis was secured in 88.8% of cases, majority of which were malignant disease. The discrepancy between navigation success and diagnostic yield was 10.1%. Target PPL located within five airway generations was associated with better diagnostic yield (95.1% vs. 58.8%, P < 0.001). There was 1 (1.0%) pneumothorax in our cohort. CONCLUSIONS Manual bronchial branch reading technique in combination with conventional rEBUS is feasible in localisation of PPL, especially for lesions located within the first five airway generations.
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Affiliation(s)
- Sze Shyang Kho
- Division of Respiratory Medicine, Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia
| | - Larry Ellee Nyanti
- Division of Respiratory Medicine, Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia
| | - Chan Sin Chai
- Division of Respiratory Medicine, Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia
| | - Swee Kim Chan
- Division of Respiratory Medicine, Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia
| | - Siew Teck Tie
- Division of Respiratory Medicine, Department of Medicine, Sarawak General Hospital, Ministry of Health, Kuching, Sarawak, Malaysia
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Abstract
The peripheral pulmonary nodule offers unique challenges to the clinician, especially in regards to diagnostic approach. Quite often the etiology of the nodule is spurious, though the specter of malignancy drives accurate classification of the nodule. Diagnostic approaches range in degrees of invasiveness, accuracy, and morbidity. Bronchoscopic access to these nodules had been plagued by low reported yields, especially in fluoroscopically invisible nodules. Navigational bronchoscopy, however, allowed more accurate access to peripheral nodules while maintaining a low morbidity, and thus reshaped the historic diagnostic algorithms. Though navigational bronchoscopy was initially associated with electromagnetic navigation, newer approaches to navigation and new technologies provide enthusiasm that yield can improve. In this article we will provide a historical approach to navigational bronchoscopy, from its origins to its current state, and we will discuss developing technology and its potential role in the evolving paradigm of the peripheral nodule biopsy.
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Affiliation(s)
- Joseph Cicenia
- Division of Bronchoscopy, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer K Avasarala
- Division of Bronchoscopy, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas R Gildea
- Division of Bronchoscopy, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Bronchoscopic interventions are preferred for sampling suspicious pulmonary lesions as they have lower complications and can achieve diagnosis and staging in one single procedure. Limitations in existing guided bronchoscopy platforms has led to developments in robotic assisted technologies. These devices may allow the bronchoscopist to more precisely maneuver the scope and instruments into the periphery of the lungs under direct visualization while also ensuring stability during sampling of the target lesions. These devices have the potential to improve the diagnostic yield in sampling peripheral lung lesions and may play a role in the treatment of non-operable or oligometastatic peripheral tumors using bronchoscopic ablative therapies. In this article, we review the existing robotic bronchoscopy technologies and summarize the available pre-clinical and clinical data supporting their use.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - D Kyle Hogarth
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary & Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA
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Abstract
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.
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Affiliation(s)
- James M Katsis
- Division of Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Otis B Rickman
- Division of Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fabien Maldonado
- Division of Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert J Lentz
- Division of Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Nashville Veterans Affairs Medical Center, Nashville, TN, USA
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Yarmus L, Akulian J, Wahidi M, Chen A, Steltz JP, Solomon SL, Yu D, Maldonado F, Cardenas-Garcia J, Molena D, Lee H, Vachani A. A Prospective Randomized Comparative Study of Three Guided Bronchoscopic Approaches for Investigating Pulmonary Nodules: The PRECISION-1 Study. Chest 2019; 157:694-701. [PMID: 31678307 DOI: 10.1016/j.chest.2019.10.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The capability of bronchoscopy in the diagnosis of peripheral pulmonary nodules (PPNs) remains limited. Despite decades of effort, evidence suggests that the diagnostic accuracy for electromagnetic navigational bronchoscopy (EMN) and radial endobronchial ultrasound (EBUS) approach only 50%. New developments in robotic bronchoscopy (RB) may offer improvements in the assessment of PPNs. METHODS A prospective single-blinded randomized controlled comparative study to assess success in localization and puncture of PPNs, using an ultrathin bronchoscope with radial EBUS (UTB-rEBUS) vs EMN vs RB in a human cadaver model of PPNs < 2 cm, was performed. The primary end point was the ability to successfully localize and puncture the target nodule, verified by cone-beam CT comparing RB and EMN. Secondary end points included needle to target position "miss" distance, and UTB-rEBUS comparisons. RESULTS Sixty procedures were performed to target 20 PPNs over the study period. Implanted PPNs were distributed across all lobes, with 80% located within the lung periphery. The target PPN mean diameter was 16.5 ± 1.5 mm, with 50% noted to have a CT bronchus sign. The rate of successful PPN localization and puncture was superior when using RB, compared with EMN (80% vs 45%; P = .02). Among unsuccessful needle passes, the median needle to target "miss" distance was significantly different when comparing UTB-rEBUS, EMN, and RB (P = .0014). CONCLUSIONS In a cadaver model, use of RB significantly increased the ability to localize and successfully puncture small PPNs when compared with existing technologies. This study demonstrates the potential of RB to precisely reach, localize, and puncture small nodules in the periphery of the lung.
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Affiliation(s)
- Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Jason Akulian
- Division of Pulmonary and Critical Care, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Momen Wahidi
- Division of Pulmonary and Critical Care, Duke University School of Medicine, Durham, NC
| | - Alex Chen
- Division of Pulmonary and Critical Care, Washington University of St. Louis School of Medicine, St. Louis, MO
| | - Jennifer P Steltz
- Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sam L Solomon
- Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Diana Yu
- Division of Pulmonary and Critical Care, Stanford University School of Medicine, Stanford, CA
| | - Fabien Maldonado
- Division of Pulmonary and Critical Care, Vanderbilt University School of Medicine, Nashville, TN
| | - Jose Cardenas-Garcia
- Division of Pulmonary and Critical Care, University of Michigan School of Medicine, Ann Arbor, MI
| | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hans Lee
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anil Vachani
- Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA; Division of Pulmonary and Critical Care, University of Pennsylvania School of Medicine, and the Corporal Michael J. Crescenz VA Medical Center Philadelphia, PA
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Ferrari-Light D, Geraci TC, Sasankan P, Cerfolio RJ. The Utility of Near-Infrared Fluorescence and Indocyanine Green During Robotic Pulmonary Resection. Front Surg 2019; 6:47. [PMID: 31448283 PMCID: PMC6696346 DOI: 10.3389/fsurg.2019.00047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/23/2019] [Indexed: 12/17/2022] Open
Abstract
During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.
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Affiliation(s)
- Dana Ferrari-Light
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, United States
| | - Travis C Geraci
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, United States
| | - Prabhu Sasankan
- School of Medicine, New York University Langone Health, New York, NY, United States
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, United States
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Aboudara M, Roller L, Rickman O, Lentz RJ, Pannu J, Chen H, Maldonado F. Improved diagnostic yield for lung nodules with digital tomosynthesis-corrected navigational bronchoscopy: Initial experience with a novel adjunct. Respirology 2019; 25:206-213. [PMID: 31265204 DOI: 10.1111/resp.13609] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/26/2019] [Accepted: 04/29/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is inferior to that of computed tomography (CT)-guided needle biopsy for pulmonary nodules. One explanation for this is divergence between the nodule location on the pre-procedure CT scan and its actual location during the procedure. Fluoroscopic ENB (F-ENB) consists of digital tomosynthesis using a conventional C-arm to re-register the target lesion based on near real-time imaging. We performed a retrospective review of ENB cases at our institution before and after introduction of F-ENB to assess diagnostic yield. METHODS All consecutive ENB procedures performed at our institution from 25 December 2017 to 25 August 2018 were reviewed. F-ENB was introduced on 25 April 2018. Two cohorts were analysed: standard ENB (S-ENB) from 25 December 2017 to 24 April 2018 and F-ENB from 25 April 2018 to 25 August 2018. All procedural, demographic and diagnostic data were collected. Descriptive statistics, chi-square, Wilcoxon test and Student's t-test were used where appropriate. A multivariable regression analysis was performed to assess factors associated with diagnostic yield. RESULTS A total of 101 and 67 nodules were biopsied in the S-ENB and F-ENB groups, respectively. Diagnostic yield was 54% in S-ENB cohort and 79% in the F-ENB group (P = 0.0019). Factors independently associated with a positive diagnosis were F-ENB and a positive radial ultrasound view (odds ratio (OR): 3.57, 95% CI: 1.56-8.18 and OR: 3.74, 95% CI: 1.37-11.05, respectively). Complications were minimal (pneumothorax: 1.5%). CONCLUSION The use of F-ENB may increase the diagnostic yield of ENB and has a low complication rate.
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Affiliation(s)
- Matt Aboudara
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lance Roller
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Otis Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jasleen Pannu
- The Division of Pulmonary Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Krimsky WS, Pritchett MA, Lau KKW. Towards an optimization of bronchoscopic approaches to the diagnosis and treatment of the pulmonary nodules: a review. J Thorac Dis 2018; 10:S1637-S1644. [PMID: 30034829 DOI: 10.21037/jtd.2018.04.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The last several years have seen substantive improvements and innovation with respect to bronchoscopic approaches to the indeterminate pulmonary nodule both diagnostically and therapeutically. Indeed, these advances have only accelerated over the last year or two and extend across multiple domains and include improvements in imaging technologies and techniques, approaches and tools to access different areas of the lung, tools to acquire tissue as well as tools and methods to ablate tissue. Needless to say, there are a variety of different approaches in terms of how these issues are being solved along with differing levels of technology and infrastructure commitments necessary to utilize these various tools, with some of these approaches being farther along than others. This article reviews some of these recent advances in the domains of advanced imaging, approaches to accessing various parts of the lung, tools designed to acquire tissue, robotic endoscopy platforms, new approaches to tissue ablation as well as potential additions to these areas that are on the horizon.
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Affiliation(s)
- William S Krimsky
- Interventional Pulmonary Medicine, Medstar Franklin Square Medical Center, Baltimore, USA
| | - Michael A Pritchett
- Department of Pulmonary Medicine, Chest Center of the Carolinas, FirstHealth Moore Regional Hospital, Pinehurst Medical Clinic, Pinehurst, North Carolina, USA
| | - Kelvin K W Lau
- Department of Thoracic Surgery, St Bartholomew's Hospital, West Smithfield, London, UK
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Abstract
INTRODUCTION Cerebral artery gas embolism (CAGE) is a rare but serious adverse event with potentially devastating neurologic sequelae. Bronchoscopy is a frequently performed procedure but with only a few reported cases of CAGE. METHODS We report the first documented case of CAGE associated with electromagnetic navigational bronchoscopy. RESULTS A 61-year-old man with a left lower lobe nodule underwent electromagnetic navigational bronchoscopy. The target lesion underwent transbronchial biopsy, brushing and an end-procedure lavage. Following the procedure, he developed seizures, evidence of hypoxic injury and cerebral edema, and air emboli were seen on computed tomography imaging. He then underwent treatment with hyperbaric oxygen with a full and complete neurologic recovery. Review of other cases reported in the literature suggests improved neurologic outcomes with hyperbaric oxygen treatment. CONCLUSIONS Biopsy techniques performed during bronchoscopy and electromagnetic navigational bronchoscopy can result in CAGE. Comparison with other reported cases suggests improved neurologic outcomes in those treated with hyperbaric oxygen. Prompt recognition of this complication and timely treatment with hyperbaric oxygen are the cornerstones to recovery.
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Affiliation(s)
- Keren Fogelfeld
- 1 Pulmonary, Critical Care and Sleep Medicine, Olive-View Medical Center, Sylmar, CA, USA.,2 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Richie K Rana
- 2 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,3 Pulmonary and Critical Care, Kaiser-Fontana Medical Center, Fontana, CA, USA
| | - Guy W Soo Hoo
- 2 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,4 Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Los Angeles, CA, USA
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Hachey KJ, Digesu CS, Armstrong KW, Gilmore DM, Khullar OV, Whang B, Tsukada H, Colson YL. A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer. J Thorac Cardiovasc Surg 2017; 154:1110-1118. [PMID: 28274559 DOI: 10.1016/j.jtcvs.2016.12.058] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 12/01/2016] [Accepted: 12/07/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate safety and feasibility of navigational bronchoscopy (NB)-guided near-infrared (NIR) localization of small, ill-defined lung lesions and sentinel lymph nodes (SLN) for accurate staging in patients with non-small cell lung cancer (NSCLC). METHODS Patients with known or suspected stage I NSCLC were enrolled in a prospective pilot trial for lesion localization and SLN mapping via NB-guided NIR marking. Successful localization, SLN detection rates, histopathologic status of SLN versus overall nodes, and concordance to initial clinical stage were measured. Ex vivo confirmation of NIR+ SLNs and adverse events were recorded. RESULTS Twelve patients underwent NB-guided marking with indocyanine green of lung lesions ranging in size from 0.4 to 2.2 cm and located 0.1 to 3 cm from the pleural surface. An NIR+ "tattoo" was identified in all cases. Ten patients were diagnosed with NSCLC and 9 SLNs were identified in 8 of the 10 patients, resulting in an 80% SLN detection rate. SLN pathologic status was 100% sensitive and specific for overall nodal status with no false-negative results. Despite previous nodal sampling, one patient was found to have metastatic disease in the SLN alone, a 12.5% rate of disease upstaging with NIR SLN mapping. SLN were detectable for up to 3 hours, allowing time for obtaining a tissue diagnosis and surgical resection. There were no adverse events associated with NB-labeling or indocyanine green dye itself. CONCLUSIONS NB-guided NIR lesion localization and SLN identification was safe and feasible. This minimally invasive image-guided technique may permit the accurate localization and nodal staging of early stage lung cancers.
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Affiliation(s)
- Krista J Hachey
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | | | - Denis M Gilmore
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Onkar V Khullar
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass; Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Brian Whang
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Hisashi Tsukada
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yolonda L Colson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass.
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