Bronchoscopy For Peripheral Pulmonary Lesions Research Articles

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Robotic-assisted bronchoscopy for peripheral pulmonary lesions: A single-center experience of the Ion platform

Rationale: The diagnostic yield of electromagnetic navigational bronchoscopy to access lung lesions remains low. The multicenter NAVIGATE study showed the diagnostic yield to be 71% for lesions up to 3 cm and 67% for lesions up to 2 cm. The introduction of robotic-assisted navigational platforms may overcome some of the traditional barriers encountered with previous approaches. We aim to assess the navigational and diagnostic yield of the Ion™ endoluminal system (Intuitive Surgical, Inc., Sunnyvale, California) regarding pulmonary lesions that could not previously be biopsied using conventional white light bronchoscopy. Methods: We retrospectively reviewed and analyzed data from our first 76 consecutive robotic-assisted navigational bronchoscopy (RAB) cases performed by a single proceduralist at our single center between March 11, 2020, to November 25, 2020. Secondary endpoints included the safety of the platform, such as incidences of pneumothoraces and significant bleeding events. Results: The ability to localize the lesion using the shape sensing technology was 100% (n=76). Navigational success, as determined by lesion visualization using radial endobronchial ultrasound confirmation, was 76% (n=58) of the nodules. The additional use of 2D-fluoroscopy for needle-in-lesion guidance and Rapid Onsite Evaluation to assess for adequate tissue sampling resulted in a diagnostic yield of 92% (n=70). There was a 0% complication rate for pneumothorax and significant bleeding events in the postoperative phase. Conclusions: Our study supports the current literature regarding the safety and efficacy of the Ion™ RAB for use in obtaining biopsy of peripheral lung lesions. Depending on the definition of navigational success, based on our results, the Ion™ RAB is comparable to or better than flexible bronchoscopy. The diagnostic yield is comparable to or better than flexible bronchoscopy but slightly lower than the gold standard computed tomography-guided transthoracic biopsy (CTTB) for peripheral lung lesions. However, in contrast to CTTB, the Ion™ RAB has lower complication rates for pneumothoraces and major bleeding. Further studies are needed to directly compare the current two robotic systems with a third system, Galaxy System™ by Noah Medical that is pending FDA approval.

Ultrathin Bronchoscopy for the Diagnosis of Peripheral Pulmonary Lesions: A Meta-Analysis

Background: Ultrathin bronchoscopy (external diameter, ≤3.5 mm) is useful for the diagnosis of peripheral pulmonary lesions because of its good accessibility. Objectives: We performed a meta-analysis to investigate the diagnostic yield of ultrathin bronchoscopy for peripheral pulmonary lesions. Methods: We performed a systematic search of MEDLINE and EMBASE (from inception to May 2021), and meta-analysis was performed using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total number of lesions, and subgroup analysis was performed to identify related factors. Results: Nineteen studies with a total of 1,977 peripheral pulmonary lesions were included. The pooled diagnostic yield of ultrathin bronchoscopy was 0.65 (95% confidence interval, 0.60–0.70). Significant heterogeneity was observed among studies (χ², 87.75; p < 0.01; I², 79.5%). In a subgroup analysis, ultrathin bronchoscopy with 1.2 mm channel size showed a diagnostic yield of 0.61 (95% confidence interval, 0.53–0.68), whereas ultrathin bronchoscopy with 1.7 mm channel size showed 0.70 (95% confidence interval, 0.66–0.74) (χ², 5.35; p = 0.02). In addition, there was a significant difference in diagnostic yield based on lesion size, histologic diagnosis (malignant vs. benign), bronchus sign, and lesion location from the hilum, whereas no significant difference was found based on lobar location. The overall complication rate of ultrathin bronchoscopy was 2.7% (pneumothorax, 1.1%). Conclusions: Ultrathin bronchoscopy is an excellent tool for peripheral pulmonary lesion diagnosis with a low complication rate. The diagnostic yield of ultrathin bronchoscopy was significantly higher with larger channel size, which might be attributed to the availability of radial endobronchial ultrasound.

Advancements in navigational bronchoscopy for peripheral pulmonary lesions: A review with special focus on virtual bronchoscopic navigation.

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.

ROBOTIC-ASSISTED BRONCHOSCOPY: A POTENTIAL NEW TOOL FOR CAVITARY PULMONARY LESIONS

ROBOTIC-ASSISTED BRONCHOSCOPY: A POTENTIAL NEW TOOL FOR CAVITARY PULMONARY LESIONS

Diagnostic usefulness of bronchoscopy for peripheral pulmonary lesions in patients with idiopathic pulmonary fibrosis.

BackgroundAs lung cancers arising in a background of idiopathic pulmonary fibrosis (IPF) are known to show high malignancy grades, early pathologic diagnosis of peripheral pulmonary lesions (PPLs) is important. Meanwhile, the risk of complications associated with diagnostic procedures is high, which prompted us to investigate the role of bronchoscopy, a relatively safe diagnostic procedure. Therefore, we conducted this study to evaluate the usefulness of bronchoscopy for the diagnosis of PPLs in patients with IPF.MethodsData of consecutive patients with IPF who underwent bronchoscopy under radial endobronchial ultrasound (R-EBUS) guidance for PPLs at our institution between April 2014 and March 2019 were retrospectively reviewed. IPF was defined as usual interstitial pneumonia (UIP) or probable UIP, in accordance with the classification in the latest global guidelines. The diagnostic outcomes and the factors independently related to the diagnostic yield were analyzed.ResultsA total of 92 patients were included in the analysis. The median (range) size of the target PPLs was 27.1 (11.4–75.3) mm, and the diagnostic yield was 82.6%. Multivariable analysis identified a larger size [P=0.017; odds ratio (OR), 5.33; 95% confidence interval (CI), 1.29–22.01], positive bronchus sign (P=0.035; OR, 4.99; 95% CI, 1.12–22.18), and not involved with UIP/probable UIP pattern (P=0.023; OR and 95% CI, unmeasurable) as being associated with a significantly higher diagnostic yield. Meanwhile, none of the patients developed acute exacerbation of IPF or pneumothorax following the diagnostic bronchoscopy.ConclusionsBronchoscopy using R-EBUS was safe and showed an acceptable diagnostic yield for PPLs, even in patients with IPF.

INIITIAL EXPERIENCE WITH STEERABLE INSTRUMENTATION IN HUMAN CADAVERIC MODELS WITH SIMULATED TUMOR TARGETS

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Despite growing experience using advanced guided techniques, the diagnostic yield of bronchoscopy for peripheral pulmonary lesions remains suboptimal, particularly for lesions which are adjacent to peripheral bronchi. While recent publications have focused on improving bronchoscopic reach, access and precision in the lung periphery, few have addressed significant modifications to the instrumentation used to obtain biopsies. This exercise was performed to evaluate two novel, steerable instruments within human cadaveric lungs with simulated tumor targets. Instrument assessment included the ability of both instruments to access simulated tumor targets in all lobes of the lung, as well as to reposition instruments within tumor targets. METHODS: Artificial tumor targets were placed in all lobes of the lungs of two human cadaver torsos which were intubated, ventilated and underwent CT scanning. Bronchoscopists utilized a large caliber bronchoscope (BF-1TH190, Olympus, Tokyo, Japan) and steerable guide sheath (2.7mm OD)(SerpeX Medical, Santa Clara, CA) by advancing, rotating and articulating the distal end of the guide sheath towards the targeted lesion using fluoroscopic guidance and a reference CT scan. Radial probe endobronchial ultrasound (UM S20-17S, Olympus Tokyo, Japan) was used to confirm lesion localization prior to performing transbronchial needle aspiration (Periview Flex, Olympus, Tokyo, Japan) and transbronchial biopsy (Precisor Broncho Forceps, ConMed, Utica, NY). Following this, a standard diagnostic bronchoscope (BF-H190, Olympus, Tokyo, Japan) was used to advance a steerable needle (1.8mm OD)(SerpeX Medical, Santa Clara, CA) towards the same targeted lesions using insertion, rotation and articulation of the distal tip. RESULTS: Both the steerable sheath and steerable needle were successfully placed within simulated tumor targets in all lobes of two cadaveric lungs with diagnostic biopsy material obtained from all lobes. Additionally, manipulation of the distal end of the steerable sheath and steerable needle was successfully used to reposition each tool within different locations of the same lesion. CONCLUSIONS: This is an initial reporting of two fully articulating, steerable instruments designed to assist with bronchoscopic biopsy of peripheral lung lesions. In this exercise both instruments were successfully positioned within tumor targets in all lobes of two human cadaveric lungs. Additionally, articulation and rotation of the distal end of each of these instruments successfully repositioned biopsy instruments within different locations of targeted lesions. CLINICAL IMPLICATIONS: Steerable instrumentation may improve the bronchoscopist's ability to place biopsy tools within targeted peripheral lesions, thereby potentially improving diagnostic yield, particularly for lesions that are positioned adjacent to peripheral bronchi. DISCLOSURES: Consultant relationship with Serpex Please note: 2020-2021 Added 04/24/2021 by Alexander Chen, source=Web Response, value=Consulting fee Removed 04/27/2021 by Alexander Chen, source=Web Response Investigator relationship with Olympus Please note: 2020-2021 Added 04/27/2021 by Alexander Chen, source=Web Response, value=Grant/Research Support Consultant relationship with Boston Scientific Please note: 2020-2021 Added 05/10/2021 by Alexander Chen, source=Web Response, value=Consulting fee Consultant relationship with Olympus America, Inc Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee Consultant relationship with Serpex Medical Please note: 1/2020 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee DSMB, consultant relationship with Novocure, Inc Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee Consultant relationship with Olympus America Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee No relevant relationships by Michael Machuzak, source=Web Response

Transbronchial needle aspiration with endobronchial ultrasonography and ultrathin bronchoscopy for peripheral pulmonary lesions.

Although the efficacy of lung cancer treatment has improved, it is dependent on a reliable diagnosis via bronchoscopy. Transbronchial biopsy using ultrathin bronchoscopy can help detect small peripheral pulmonary lesions (PPLs), with a high diagnostic yield. However, the diagnosis rate using forceps biopsy when the radial endobronchial ultrasonography (rEBUS) probe is adjacent to a lesion tends to be low. Transbronchial needle aspiration (TBNA) may improve the diagnostic yield from adjacent lesions. Recently, PeriView FLEX, a new TBNA needle that can be inserted into ultrathin bronchoscopes, has become available. We examined whether TBNA with PeriView FLEX and forceps biopsy improved adjacent lesion diagnosis when using ultrathin bronchoscopes. We retrospectively examined 51 consecutive patients who underwent TBNA and forceps biopsy using ultrathin bronchoscopes under rEBUS for small PPLs at the Hakodate Goryoukaku Hospital between November 2019 and August 2020. The histological diagnosis rate using TBNA and forceps biopsy, TBNA alone, or forceps biopsy alone was compared between cases where the rEBUS probe was "Within" and "Adjacent To" the lesions. The diagnosis rate using TBNA and forceps biopsy was 86.3% (95.7% vs. 78.6%; p=0.08) for all lesions (Within cases vs. Adjacent To cases). The corresponding rate using TBNA alone was 68.6% (69.6% vs. 67.9%; p=0.57), and that using forceps biopsy alone was 72.5% (91.3% vs. 57.1%; p=0.0067). Forceps biopsy with TBNA during ultrathin bronchoscopy for small PPLs improved the diagnostic yield when lesions were adjacent to the rEBUS probe.

Robotic bronchoscopy for peripheral pulmonary lesions: a convergence of technologies.

Robotic bronchoscopy is the newest advanced diagnostic bronchoscopy technology for biopsying peripheral pulmonary lesions; sensitivity for malignancy is currently suboptimal using modalities, such as radial endobronchial ultrasound or electromagnetic navigational bronchoscopy. We review the pitfalls of prior methods and the technological advancements with robotic bronchoscopy. The contributors to reduced diagnostic sensitivity with current approaches include limitations in: navigation to the target, confirmation once the target is reached, and tissue acquisition. CT to body divergence with virtual reality methods, such as with electromagnetic navigation, potential false-positive confirmation with radial endobronchial ultrasound because of intraprocedural induced atelectasis, and lack of bronchoscopic and instrument maneuverability are all limitations to improving sensitivity. Robotic bronchoscopy enhances navigation through target pathway selection, allows for further reach in the distal airways, and improves tissue acquisition with more flexible and maneuverable biopsy instruments but lacks a high-fidelity target confirmation system. Robotic bronchoscopy shows promise in biopsying peripheral lesions. Current published studies focus on diagnostic yield with robotic bronchoscopy. Future studies with long-term follow-up will be needed to assess diagnostic sensitivity for lung cancer and if robotic bronchoscopy is superior to other advanced diagnostic bronchoscopic techniques for peripheral pulmonary lesions.

Virtual bronchoscopic navigation versus non-virtual bronchoscopic navigation assisted bronchoscopy for the diagnosis of peripheral pulmonary lesions: a systematic review and meta-analysis.

Background:Image-guided bronchoscopy techniques such as virtual bronchoscopic navigation (VBN) has emerged as a means of assisting in the biopsy of peripheral pulmonary lesions. However, the role of VBN-assisted (VBNA) bronchoscopy in the diagnosing of peripheral pulmonary lesions (PPLs) has not been well established. This meta-analysis investigated the diagnostic yield of VBN-assisted versus non-VBN-assisted (NVBNA) bronchoscopy for PPLs.Methods:PubMed, Embase, Cochrane library, and Web of Sciences databases were searched up to and including August 2020 to identify randomized controlled trials (RCTs) evaluating the performance of VBNA compared with an NVBNA group. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI).Results:Six RCTs with 1626 patients were included. The overall diagnostic rate was similar in the VBNA (74.17%) and NVBNA (69.51%) groups, with risk ratio of 1.07 (95% CI: 0.98–1.17). However, in the VBNA group, the total examination time was significantly shorter (MD = −3.94 min, 95% CI: −6.57 to −1.36; p = 0.003) than in the NVBNA group. VBNA had superior diagnostic yield than NVBNA for PPLs ⩽ 20 mm (RR = 1.18, 95% CI: 1.05–1.32). In addition, diagnostic yield according to nature of lesion, lesion location in the lung lobe, distance from the hilum, bronchus sign and complications were similar between VBNA and NVBNA groups.Conclusion:VBNA bronchoscopy did not increase overall diagnostic yield in patients with PPLs compared with NVBNA bronchoscopy. The superiority of VBNA over NVBNA was evident among patients with PPLs ⩽ 20 mm. Future multicenter RCTs are needed for further investigation. The reviews of this paper are available via the supplemental material section.

Improving diagnostic yield of navigational bronchoscopy for peripheral pulmonary lesions: a review of advancing technology.

With recommendations for low dose CT scan for lung cancer screening, there has been an increase in the finding of lung nodules and peripheral pulmonary lesions (PPLs). Additionally, when there is concern for malignancy, guidelines have recommended performing the least invasive evaluation. Conventional bronchoscopy diagnostic yields for PPLs have reportedly been quite low and prior electromagnetic navigation bronchoscopy (ENB) studies have reported variable yields. Navigation bronchoscopy in addition to endobronchial ultrasound allows a physician to evaluate peripheral lung lesions along with mediastinal and hilar lymph nodes for the diagnosis and staging of suspected malignancy in one procedure. More recent advances in navigational bronchoscopy including the use of augmented fluoroscopy (AF), cone beam CT, and robotic bronchoscopy have pushed the boundaries of capability in evaluating PPLs. These added bronchoscopic technologies have shown to improve diagnostic yield especially when modalities are used in combination. The ultimate goal of endoscopically localized ablative and therapeutic treatment for peripheral lung lesions will require a high level of physician confidence, accuracy, and precision. This article will review the innovative characteristics and data of some of the more recently available navigational bronchoscopy devices.

Diagnostic value of ultrathin bronchoscopy in peripheral pulmonary lesions: a narrative review.

Flexible bronchoscopes are being continuously improved, and an ultrathin bronchoscope with a working channel that allows the use of a radial-type endobronchial ultrasound (EBUS) probe is now available. The ultrathin bronchoscope has good maneuverability for passing through the small bronchi and good accessibility to peripheral lung lesions. This utility is particularly enhanced when it is used with other imaging devices, such as EBUS and navigation devices. Multimodality bronchoscopy using an ultrathin bronchoscope leads to enhanced diagnostic yield.

Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT)

BackgroundThe diagnosis of peripheral pulmonary lesions (PPL) continues to present clinical challenges. Despite extensive experience with guided bronchoscopy, the diagnostic yield has not improved significantly. Robotic-assisted bronchoscopic platforms have been developed potentially to improve the diagnostic yield for PPL. Presently, limited data exist that evaluate the performance of robotic systems in live human subjects.Research QuestionWhat is the safety and feasibility of robotic-assisted bronchoscopy in patients with PPLs?Study Design and MethodsThis was a prospective, multicenter pilot and feasibility study that used a robotic bronchoscopic system with a mother-daughter configuration in patients with PPL 1 to 5 cm in size. The primary end points were successful lesion localization with the use of radial probe endobronchial ultrasound (R-EBUS) imaging and incidence of procedure related adverse events. Robotic bronchoscopy was performed in patients with the use of direct visualization, electromagnetic navigation, and fluoroscopy. After the use of R-EBUS imaging, transbronchial needle aspiration was performed. Rapid on-site evaluation (ROSE) was used on all cases. Transbronchial needle aspiration alone was sufficient when ROSE was diagnostic; when ROSE was not diagnostic, transbronchial biopsy was performed with the use of the robotic platform, followed by conventional guided bronchoscopic approaches at the discretion of the investigator.ResultsFifty-five patients were enrolled at five centers. One patient withdrew consent, which left 54 patients for data analysis. Median lesion size was 23 mm (interquartile range, 15 to 29 mm). R-EBUS images were available in 53 of 54 cases. Lesion localization was successful in 51 of 53 patients (96.2%). Pneumothorax was reported in two of 54 of the cases (3.7%); tube thoracostomy was required in one of the cases (1.9 %). No additional adverse events occurred.InterpretationThis is the first, prospective, multicenter study of robotic bronchoscopy in patients with PPLs. Successful lesion localization was achieved in 96.2% of cases, with an adverse event rate comparable with conventional bronchoscopic procedures. Additional large prospective studies are warranted to evaluate procedure characteristics, such as diagnostic yield.Clinical Trial RegistrationClinicalTrials.gov; No.: NCT03727425; URL: www.clinicaltrials.gov.

Conventional vs Ultrathin Bronchoscopy for Peripheral Pulmonary Lesions

Conventional vs Ultrathin Bronchoscopy for Peripheral Pulmonary Lesions

Computed Tomography Bronchus Sign and the Diagnostic Yield of Guided Bronchoscopy for Peripheral Pulmonary Lesions. A Systematic Review and Meta-Analysis.

Indeterminate peripheral pulmonary lesions (PPLs) often require tissue diagnosis. If nonsurgical biopsy techniques are considered, deciding between bronchoscopic transbronchial versus computed tomography-guided transthoracic biopsy can be difficult. The former has a low diagnostic yield with a low complication risk, whereas the latter has a better diagnostic yield but a higher complication rate. Investigators have looked at various lesion characteristics that can predict the diagnostic yield of guided bronchoscopic biopsies. Although consensus exists that larger size and proximity to the hilum increase the diagnostic yield, there is ongoing debate about the association between computed tomography bronchus sign (air-filled bronchus in close proximity of the lesion as seen on computed tomography imaging) and the diagnostic yield of guided bronchoscopic modalities. To perform a meta-analysis and systematic review, determining the association between computed tomography bronchus sign and the diagnostic yield of guided bronchoscopy for PPLs. MEDLINE, Embase, Scopus, and Google Scholar were searched in January 2018 for guided bronchoscopy studies that had assessed the impact of computed tomography bronchus sign on the diagnostic yield. The quality of included studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 tool. Meta-analysis was performed using MedCalc (version 18). Odds ratios were used to compare yield of lesions with and without bronchus sign. Random effects model was used when significant heterogeneity was observed (I2 > 40%). For 2,199 lesions with computed tomography bronchus sign, the overall weighted diagnostic yield was 74.1% (95% confidence interval, 68.3-79.5%). For 971 lesions without computed tomography bronchus sign, the overall weighted diagnostic yield was 49.6% (95% confidence interval, 39.6-59.5%). The odds ratio for successfully diagnosing a lesion with computed tomography bronchus sign was 3.4 (95% confidence interval, 2.4-5.0). Possible sources of heterogeneity in the meta-analysis included differences in study designs, guidance modalities, and cancer prevalence. The odds ratio for successfully diagnosing a lesion with computed tomography bronchus sign was relatively lower for prospective studies. PPLs with computed tomography bronchus sign are more likely to be diagnosed with guided bronchoscopy than the lesions without computed tomography bronchus sign. Clinicians should consider this, along with the lesion size and distance from the hilum, when contemplating guided bronchoscopy for PPLs.

Robotic Endoscopic Airway Challenge: REACH Assessment

Bronchoscopy for peripheral pulmonary lesions continues to present challenges to clinicians. One potential limitation may be the inability to advance conventional bronchoscopes into close proximity of peripheral lesions before biopsy. This study was performed to assess the reach of a robotic endoscopic system within human cadaveric lungs compared with conventional thin bronchoscopes. All segmental bronchi (RB1 to 10, LB1 to 10) were accessed in two human cadavers using a conventional thin bronchoscope and robotic endoscope of identical outer diameter. Bronchus generation count and insertion depth measured by electromagnetic navigation and external fluoroscopy were recorded. The robotic endoscope was advanced beyond the conventional thin bronchoscope in all segments, particularly in bronchi with increased angulation such as RB1 (mean generation count 8 versus 3.5, respectively) and LB1+2 (mean generation count 8 versus 4.5). The robotic endoscopic system was advanced beyond a conventional thin bronchoscope with identical outer diameter into the periphery of human cadaveric lungs. Improved reach within the lung periphery may address some limitations with contemporary bronchoscopic approaches for peripheral lesion biopsy.

Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation.

Rapid on-site evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions, but few reports had been carried out to confirm the utility in the diagnosis of peripheral pulmonary lesions (PPLs) by radial probe endobronchial ultrasound (R-EBUS). To evaluate the impact of ROSE on the diagnostic yield of R-EBUS for PPLs, we retrospectively analyzed the diagnostic yields of transbronchial biopsy (TBB) or brushing using R-EBUS for patients with PPLs in a tertiary university hospital from December 2012 to December 2014. A total of 815 patients with PPLs were included. A definite diagnosis was made by R-EBUS-guided TBB or brushing for 627 patients (76.9%). A total of 279 patients (34.2%) were examined by a ROSE technique. The combination of R-EBUS guided TBB or brushing with ROSE raised the diagnostic yield in the diagnosis of PPLs, especially difficult cases: right apical and left apical-posterior segment locations, small PPLs <3 cm without bronchus signs on computed tomography (CT) scan, PPLs with pleural effusions, and the position of probe is not within. ROSE can improve the PPLs diagnostic yield when using R-EBUS guided TBB or brushing.

Diagnostic utility of endobronchial ultrasound with a guide sheath under the computed tomography workstation (ziostation) for small peripheral pulmonary lesions.

The application of radial probe endobronchial ultrasound (R-EBUS) and virtual bronchoscopic navigation has improved the diagnostic outcome of bronchoscopy for peripheral pulmonary lesions (PPLs). Nonetheless, while existing navigation systems are very useful for selecting the bronchus containing the target lesion, the associated introductory costs are high. Therefore, we focused on virtual bronchoscopy (VB) using the workstation, ziostation that was already available in many countries as an adjunct modality. Consecutive patients who underwent bronchoscopy with R-EBUS for PPLs (major diameter ≤30 mm) were enrolled. From late June 2013 to November 2013, 121 patients were examined with ziostation, and from September 2012 to early June 2013, 113 patients were examined without ziostation. We compared the diagnostic yield, EBUS detection rate and procedure time between two groups to evaluate the utility of the VB. The ziostation group had significantly higher diagnostic yield than the non-ziostation group (77.7% vs 64.6%, P = 0.030). Following the multivariate analysis, use of ziostation was a significant factor affecting the diagnostic yield. Meanwhile, EBUS detection rate was significantly higher in the ziostation group (94.2% vs 75.2%, P < 0.001). And, procedure time was significantly shorter in the ziostation group (mean ± standard deviation: 24.0 ± 7.4 min vs 26.9 ± 7.9 min, P = 0.005). VB offered by the workstation was a valuable tool that facilitated more accurate and rapid bronchoscopy procedure for diagnosis of PPLs.

Endobronchial Ultrasonography in Bronchoscopic Occult Pulmonary Lesions

The diagnostic yield of flexible bronchoscopy for peripheral pulmonary lesions is variable and often limited. Endobronchial ultrasonography (EBUS) has been reported to help localize a bronchoscopic occult pulmonary lesion and thereby improve the diagnostic yield of transbronchial biopsy (TBB). We evaluated the yield of EBUS-guided TBB in 50 consecutive patients with a bronchoscopic occult pulmonary lesion. The mean diameter of the lesions was 36.6 mm (SD = 19.7 mm). We could visualize 74% of the bronchoscopic occult lesions with EBUS, and in these patients, a histologic diagnosis on TBB was obtained in 84%. However, the diagnostic yield was very poor for lesions <20 mm. EBUS-guided TBB is effective for localizing and diagnosing bronchoscopic occult pulmonary masses > or =20 mm, but its yield remains unsatisfactory for lesions <20 mm.