Electromagnetic Navigation Bronchoscopy Research Articles

Bronchoscopic diagnosis of peripheral lung lesions.

Over the last decades, in addition to the traditional fluoroscopy, various and innovative guidance systems have been adopted in clinical practice for transbronchial approach to peripheral pulmonary lesions (PPLs). The aim of this article is to summarize the most recent data on available guidance systems and sampling tools, evaluating also advantages and limitations of each technique. Although several studies have been published over the last years, large randomized studies comparing the different techniques are scanty. Fluoroscopy is the traditional and still most widely utilized guidance system. New guidance systems (electromagnetic navigation bronchoscopy, ultrasound miniprobe, cone beam computed tomography) seems to provide a better sensitivity, especially for small lesions not visualized by fluoroscopy. Among the sampling instruments, there is a good evidence that flexible transbronchial needle provides the better diagnostic yield and that sensitivity may increase if more than one sampling instrument is used. Even if great progress has been done since the first articles on the transbronchial approach to PPLs, better scientific evidence and more reliable randomized trials are needed to guide interventional pulmonologists in choosing the best technique according to different clinical scenarios and source availability.

Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report

Abstract Introduction/Objective DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection. Methods/Case Report A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets. Results (if a Case Study enter NA) NA Conclusion It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.

Electromagnetic navigation bronchoscopy versus virtual bronchoscopy navigation for improving the diagnosis of peripheral lung lesions: analysis of the predictors of successful diagnosis.

To investigate if electromagnetic navigation bronchoscopy (ENB) improves the diagnostic yield for peripheral lung lesions from that achieved by virtual bronchoscopy navigation (VBN). This retrospective study compared the results of 100 ENB-transbronchial lung biopsies (TBLBs) with those of 50 VBN-TBLBs at a single institution. ENB improved the diagnostic yield significantly compared with VBN (64.0% for 19.4 ± 9.0mm tumors vs. 46.0% for 27.6 ± 8.9mm tumors; p < 0.0001). Irrespective of the bronchus sign, ENB was more favorable than VBN, with 81.0% (47/58) achieved by ENB vs. 60.0% (21/35) achieved by VBN in the presence of the positive bronchus sign (p = 0.0283), and 40.5% (17/42) achieved by ENB vs. 13.3% (2/15) achieved by VBN in the absence of the bronchus sign (p = 0.0431). Univariate analysis identified tumor size (p = 0.0048), amount of intravenous sedation (p = 0.0182), registration time (p = 0.0111), minimum distance to target (p = 0.0244), and the bronchus sign (p < 0.0001) as factors that affected the yield significantly for ENB. Multivariate analysis identified the bronchus sign (odds ratio 6.74; 95% CI 1.84-24.7) and the registration time (OR 1.01; 95% CI 1.00-1.02) as significant factors. Despite the bronchus sign being a significant factor, ENB improved the diagnostic yield of smaller lesions significantly, compared with VBN, regardless of the bronchus sign.

Advances in Diagnostic Bronchoscopy.

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

Cone beam CT augmented fluoroscopy allows safe and efficient diagnosis of a difficult lung nodule

BackgroundDetection of small peripheral lung nodules is constantly increasing with the development of low dose computed tomography lung cancer screening programs. A tissue diagnosis is often required to confirm malignity, with endobronchial biopsies being associated with a lower pneumothorax rate than percutaneous approaches. Endoscopic diagnosis of peripheral small size lung nodules is however often challenging using traditional bronchoscopy and endobronchial ultrasound alone. New virtual bronchoscopic navigation techniques such as electromagnetic navigational bronchoscopy (ENB) have developed to improve peripheral navigation, with diagnostic yield however remaining in the 30–50% range for small lesions. Recent studies have shown the benefits of combining Cone beam computed tomography (CBCT) with ENB to improve diagnostic yield to up to 83%. The use of ENB however remains limited by disposable cost, bronchus sign dependency and inaccuracies due to CT to body divergence.Case presentationThis case report highlights the feasibility and usefulness of CBCT-guided bronchoscopy for the sampling of lung nodules difficult to reach through traditional bronchoscopy because of nodule size and peripheral position. Procedure was scheduled in a mobile robotic hybrid operating room with patient under general anaesthesia. CBCT acquisition was performed to localize the target lesion and plan the best path to reach it into bronchial tree. A dedicated software was used to segment the lesion and the bronchial path which 3D outlines were automatically fused in real time on the fluoroscopic images to augment live guidance. Navigation to the lesion was guided with bronchoscopy and augmented fluoroscopy alone. Before the sampling, CBCT imaging was repeated to confirm the proper position of the instrument into the lesion. Four transbronchial needle aspirations (TBNA) were performed and the tissue analysis showed a primary lung adenocarcinoma.ConclusionsCBCT and augmented fluoroscopy technique is a safe and effective and has potential to improve early stage peripheral lesions endobronchial diagnostic yield without ENB. Additional studies are warranted to confirm its safety, efficacy and technical benefits, both for diagnosis of oncological and non-oncological disease and for endobronchial treatment of inoperable patients.

Risk Factors for Invisible Intraoperative Markings After Virtual-Assisted Lung Mapping

BackgroundVirtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking technique that can be combined with bronchoscopic placement of a microcoil (VAL-MAP 2.0). VAL-MAP can identify unpalpable pulmonary lesions; however, the markings are occasionally deemed invisible intraoperatively. We investigated preoperative risk factors for invisible markings after VAL-MAP. MethodsWe prospectively performed preoperative VAL-MAP in patients at the University of Tokyo between January 2014 and June 2020. Data of 219 patients (257 lesions) and 857 markings were retrospectively reviewed. Dye markings were categorized as grade 0 (invisible) or 1-5 (visible). The risk factors for grade 0 markings were assessed using multiple logistic regression analysis. Subsegments of the bronchus showing grade 0 markings were also evaluated for 133 lesions and 504 markings without missing data for the target segment. ResultsSixty-one of the 257 lesions (24%) displayed ≥1 grade 0 markings. Seventy-six (8.9%) of the 857 markings were grade 0 intraoperatively. VAL-MAP 1.0 was performed for 202 (79%) and 25 lesions (10%) without and with electromagnetic navigation bronchoscopy, and VAL-MAP 2.0 with a microcoil was performed for 30 lesions (11%). Upper lobe markings were associated with a significantly increased risk of invisible markings. There was no significant difference in the frequency of grade 0 markings among the VAL-MAP methods. Among all bronchi subsegments, left B1+2c exhibited the highest rate of grade 0 markings. ConclusionsMarkings placed using VAL-MAP are more likely to be invisible for upper lobe pulmonary lesions. Injecting markings for lesions in the left S1+2c thus require caution.

IMPACT OF PERCEPTA BRONCHIAL GENOMIC CLASSIFIER ON LUNG NODULE MANAGEMENT AT AN ACADEMIC MEDICAL CENTER

TOPIC: Lung Pathology TYPE: Late Breaking PURPOSE: A nondiagnostic bronchoscopic biopsy of a pulmonary nodule presents a challenging clinical dilemma. Risk of alternative biopsy strategies must be weighed against the risk of a delayed diagnosis from continued surveillance. The Percepta Genomic Sequencing Classifier (GSC) is a gene expression classifier that utilizes whole transcriptome RNA sequencing from bronchial brushings to risk stratify lung nodules by both down classifying risk of malignancy (ROM) with high sensitivity, as well as up classifying ROM with high specificity in former or current smokers. We report our experience with the Percepta GSC in reclassifying the pretest ROM in both smokers and non-smokers. METHODS: This is an IRB approved single center retrospective review of all patients for which Percepta GSC was utilized following a nondiagnostic electromagnetic navigational bronchoscopy (ENB) from November 2018 to December 2020. Data collected included nodule characteristics, smoking history, pre- and post-test ROM, additional invasive and non-invasive testing, complications, and final diagnosis. The proportion of the patients who were re-classified and final outcomes were recorded. RESULTS: Percepta GSC was utilized in 29 of 204 ENB cases during the study period. 55% of Percepta GSC subjects were male, and 83% were former or current smokers. Five (17%) patients were never smokers. Mean nodule size was 2.5 cm (range: 0.8-8.0 cm). In the smoker cohort, 58% and 42% of patients had intermediate and high pretest ROM, respectively. 31% of patients were reclassified with Percepta GSC. In smokers with an intermediate pretest ROM, 28% were reclassified (2 each into the low and high-risk categories). In the smoker cohort with high pretest ROM, 30% were reclassified and all were up classified to the very high ROM category. In the intermediate pretest ROM category in non-smokers, 40% were reclassified, and all were down-classified into the low-risk category. Four patients (14%) (2 from each cohort) were reclassified to low risk from intermediate risk. None of them required any additional invasive evaluation. Two of them demonstrated stability on surveillance imaging, one was confirmed benign on a subsequent biopsy, and one was diagnosed with blastomycosis. Five patients were up classified, and all of them were in the smoker cohort. Two of these five were diagnosed with pulmonary malignancy after further testing. CONCLUSIONS: Approximately one-third of patients were reclassified by the Percepta GSC after a nondiagnostic bronchoscopy. Percepta GSC is a valuable addition to the pulmonary nodule management algorithm. CLINICAL IMPLICATIONS: Down classification of ROM with the Percepta GSC classifier helps low risk patients avoid further invasive diagnostic evaluation. Up classification of nodules with the Percepta GSC should warrant further evaluation for malignancy. DISCLOSURES: No relevant relationships by Mohammed Abdalla, source=Web Response No relevant relationships by Bryan Benn, source=Web Response No relevant relationships by Chinmay Jani, source=Web Response Speaker/Speaker's Bureau relationship with Biodesix Please note: 2018 - present Added 05/23/2021 by Jonathan Kurman, source=Web Response, value=Honoraria Consultant relationship with Level Ex Please note: 2018 - present Added 05/23/2021 by Jonathan Kurman, source=Web Response, value=Consulting fee Consultant relationship with Medtronic Please note: 2020 - present Added 05/23/2021 by Jonathan Kurman, source=Web Response, value=Consulting fee educational courses relationship with Pinnacle Biologics Please note: 2020 - present Added 05/23/2021 by Jonathan Kurman, source=Web Response, value=Travel Consultant relationship with Boston Scientific Please note: 2021 - present Added 05/23/2021 by Jonathan Kurman, source=Web Response, value=Consulting fee Consultant relationship with Cook Medical Please note: 2021 - present Added 05/22/2021 by Jonathan Kurman, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with Erbe Please note: 2021 - present Added 05/22/2021 by Jonathan Kurman, source=Web Response, value=Honoraria research panel relationship with Intuitive Please note: 2020 - present Added 05/22/2021 by Jonathan Kurman, source=Web Response, value=Honoraria Consultant relationship with Pulmonx Please note: 2020 - present Added 05/22/2021 by Jonathan Kurman, source=Web Response, value=Consulting fee No relevant relationships by Harpreet Singh, source=Web Response

ROBOTIC BRONCHOSCOPY: OUR FIRST 100 NODULES

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Diagnosis of peripheral pulmonary lung nodules is a clinical challenge requiring a multi-disciplinary approach. Robotic bronchoscopy (RB) has come into the forefront of novel diagnostic procedures allowing for visualization and stable access to distal airways providing better access to nodules. However, limited data currently exist as to the diagnostic yield of RB and the learning curve required to become proficient. METHODS: This was a retrospective, single center study utilizing the robotic bronchoscope (Ion, Intuitive Medical) to sample peripheral pulmonary nodules. Data collected include nodule characteristics, length of procedure, use of linear endobronchial ultrasound (EBUS), and overall yield for malignant and benign nodules. Results from the first 6 months of use were compared to results from the last 8 months. Samples which were atypical or did not show a definite benign or malignant diagnosis were classified as non-diagnostic. Nodules were classified into true positive (TP), true negative (TN), or false negative (FN). TP were nodules with biopsy positive carcinoma or a defined benign diagnosis. TN nodules were non-diagnostic that had a benign diagnosis confirmed by resection, or follow-up imaging demonstrating decreased size of the nodule or a minimum of 6 months of stability. FN nodules were non-diagnostic and subsequently found to be cancer or treated as such with empiric radiation. RESULTS: 95 patients with 103 nodules were biopsied between February 2020 and April 2021. Median lesion size was 19 mm (range 7- 69mm). Based on RB 9(8.7%) of biopsies were benign, 60(58%) malignant and 34(33%) non-diagnostic. Benign RB diagnosis included hamartoma, fungal elements, organizing pneumonia and granulomas. In the non-diagnostic group 23/33 had complete follow up data and 13 (57%) were confirmed as benign.When comparing the first 6 months to the last 8 months the TP rate improved from 20/33 (61%) to 49/60 (82%) and the FN rate decreased from 4/33(12.1%) to 6/60 (10%) (p=0.0415). A total of 70 nodules were ultimately defined as malignant. RB confirmed diagnosis in 60(86%) of those. In the first 6 months malignancy was confirmed in 19/23 (83%) and this improved to 41/47 (87%; p=0.72).The average procedure time for RB did not differ significantly between the first 6 months and thereafter (81.9min vs 70.9min, p =0.1300). The procedure time for RB with EBUS decreased significantly from 138.9min to 104.5min (p = 0.0081). CONCLUSIONS: In this study, a learning curve effect was seen with significant improvements in TP/FN rates, and shorter procedure times when performed in conjunction with EBUS. In patients with cancer, RB is even more effective with yield as high as 87%. CLINICAL IMPLICATIONS: Our initial experience shows excellent results that may be superior to electromagnetic navigation bronchoscopy. A learning curve was demonstrated. DISCLOSURES: No relevant relationships by Stephanie Baltaji, source=Web Response No relevant relationships by Hiran Fernando, source=Web Response Speaker/Speaker's Bureau relationship with AstraZeneca Please note: $5001 - $20000 Added 11/30/2020 by Sohini Ghosh, source=Web Response, value=Consulting fee Consultant relationship with Intuitiv Please note: $1001 - $5000 Added 11/30/2020 by Sohini Ghosh, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with AstraZeneca Please note: 2013-2021 Added 04/30/2021 by Benny Weksler, source=Web Response, value=Consulting fee No relevant relationships by Ping Zheng, source=Web Response

Learning Curves for Electromagnetic Navigation Bronchoscopy Using CUSUM Analysis.

Electromagnetic navigation bronchoscopy (ENB) is a relatively new and technically demanding procedure for the guidance of bronchoscopic biopsy to help locate small lung lesions. The results in experienced hands are well described. However, we do not know the results in unexperienced hands-in other words, we have no knowledge about how fast you can learn the procedure. The aim of this study was to draw learning curves for beginners in ENB using Cumulated Sum (CUSUM) analysis, a method for quantitative evaluation of the learning curves for clinical procedures. Four operators from 3 centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or nondiagnostic based on sample adequacy. Learning curves were drawn based on diagnostic yield. A total of 215 procedures were assessed. For 2 of the operators (operators 1 and 4), at least 25 to 30 procedures were necessary to obtain competency whereas operators 2 and 3 showed more horizontal learning curves indicating an overweight of diagnostic procedures from the beginning. Operators achieve competences in ENB at different paces. This must be taken in account when beginners start to learn the procedure. There is a huge need for a structured educational program and a validated test to determine competences.

4D Electromagnetic Navigation Bronchoscopy for the Sampling of Pulmonary Lesions: First European Real-Life Experience

PurposeThe use of Electromagnetic navigation bronchoscopy (ENB) for the diagnosis of pulmonary peripheral lesions is still debated due to its variable diagnostic yield; a new 4D ENB system, acquiring inspiratory and expiratory computed tomography (CT) scans, overcomes respiratory motion and uses tracked sampling instruments, reaching higher diagnostic yields. We aimed at evaluating diagnostic yield and accuracy of a 4D ENB system in sampling pulmonary lesions and at describing their influencing factors.MethodsWe conducted a three-year retrospective observational study including all patients with pulmonary lesions who underwent 4D ENB with diagnostic purposes; all the factors potentially influencing diagnosis were recorded.Results103 ENB procedures were included; diagnostic yield and accuracy were, respectively, 55.3% and 66.3%. We reported a navigation success rate of 80.6% and a diagnosis with ENB was achieved in 68.3% of cases; sensitivity for malignancy was 61.8%. The majority of lesions had a bronchus sign on CT, but only the size of lesions influenced ENB diagnosis (p < 0.05). Transbronchial needle aspiration biopsy was the most used tool (93.2% of times) with the higher diagnostic rate (70.2%). We reported only one case of pneumothorax.ConclusionThe diagnostic performance of a 4D ENB system is lower than other previous navigation systems used in research settings. Several factors still influence the reachability of the lesion and therefore diagnostic yield. Patient selection, as well as the multimodality approach of the lesion, is strongly recommended to obtain higher diagnostic yield and accuracy, with a low rate of complications.

Overview of Interventional Pulmonology for Radiologists.

Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ©RSNA, 2021.

Sight Unseen: Diagnostic Yield and Safety Outcomes of a Novel Multimodality Navigation Bronchoscopy Platform with Real-Time Target Acquisition

Background: Several advanced bronchoscopy platforms are currently available, but the clinical data supporting their use vary. Electromagnetic navigation bronchoscopy (ENB) remains the dominant technology; it is limited by its reliance on preoperative computed tomography, which only approximates patient anatomy during the procedure. Recently, ENB was enhanced with the (1) addition of digital tomosynthesis-based navigation correction, (2) improvements in planning algorithms, and (3) continuous real-time guidance (Illumisite™; Medtronic, Minneapolis, MN, USA). There are currently no clinical data on the diagnostic yield and safety profile of this system. Objectives: The primary objective of this study is to describe the diagnostic yield of the first 100 pulmonary parenchymal lesions sampled using the multimodality navigation bronchoscopy (MNB) platform. The secondary objective is to describe safety. Methods: In this single-center prospective observational study, a database was maintained to track patient, procedural, and outcome data for the first 100 consecutive lesions sampled using the MNB platform at an academic quaternary referral center. Descriptive statistics and univariate and multivariate analyses are reported. Results: The overall diagnostic yield of samples acquired was 79% (79/100). In the cohort where digital tomosynthesis was used, the diagnostic yield was 83% (69/83). Sensitivity for malignancy was 71% (52/73). Overall complication rates were low: pneumothorax (n = 3, 3%) and bleeding requiring intervention (n = 2, 2%). There were no procedural-related hospital admissions. Conclusions: The MNB system performed favorably. Platform superiority cannot be established without future prospective and comparative studies.

Expert Consensus on Technical Specifications of Domestic Electromagnetic Navigation Bronchoscopy System in Diagnosis, Localization and Treatment (2021 Edition)

电磁导航支气管镜(electromagnetic navigation bronchoscopy, ENB)是以电磁定位技术为基础，结合虚拟支气管镜、三维计算机断层扫描(computed tomography, CT)成像和呼吸门控技术的新型支气管镜检查手段，该技术已在临床中广泛应用。近年来，国产电磁导航系统也得到了较快发展，其在肺外周病变诊断、定位和治疗中的有效性和安全性已得到初步验证，为优化和标准化国产ENB技术操作规范，指导其在临床实践中的应用，中国医学装备协会呼吸病学装备技术专业委员会和国产电磁导航支气管镜技术专家组组织专家讨论并制定了本专家共识。

Lung Nodule Evaluation Using Robotic-Assisted Bronchoscopy at a Veteran's Affairs Hospital.

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.

Diagnostic Performance of Electromagnetic Navigation Bronchoscopy-Guided Biopsy for Lung Nodules in the Era of Molecular Testing.

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

Electromagnetic navigation-guided preoperative localization: the learning curve analysis.

BackgroundThe electromagnetic navigation bronchoscopy (ENB) was increasingly used to mark small pulmonary nodules (PNs) for video-assisted thoracic surgery (VATS) resection due to high effectiveness and low risk. However, no study reports the learning curve of ENB-guided preoperative localization. In the study, we aimed to describe the learning curve of ENB-guided preoperative PNs localization initially.MethodsConsecutive PNs cases that underwent ENB localizations between October 2018 and October 2019 by the same surgeon in our center were included in the study. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB localization.ResultsA total of 89 ENB localization from 64 patients were included in this study. The learning curve was divided into 3 phases: Phase I (the initial 11 cases), Phase II (the 12th to the 47th cases), and Phase III (the 47th to the 89th cases). The success rate of ENB localization has increased with the accumulation of operational experience in 3 phases (72.73%, 91.67%, and 97.62%, P=0.049). The distance from the ENB guide wire tip to the center of the lesion in Phase I was significantly longer than those in Phase II and Phase III (2.46±1.76 vs. 1.36±0.94 and 1.47±0.97 cm, P=0.014 and 0.027, respectively). Sex, bronchus sign, and learning curve phase were independent risk factors influencing operative time (OT) (OR =8.187, 18.847, and 13.920, respectively).ConclusionsThe technical competency, which is indicated by higher success rate, localization accuracy, and shorter OT, for ENB-guided preoperative PNs localization was achieved at the 47th operation.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection.

BackgroundThoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.MethodsFrom January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.ResultsForty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9–14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6–16 mm). The median ENB length was 25 min (19–33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.ConclusionsENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Updates and controversies in anesthesia for advanced interventional pulmonology procedures.

Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Feasibility of comprehensive genotyping specimens from radial endobronchial ultrasonography and electromagnetic navigation bronchoscopy.

IntroductionMini-invasive bronchoscopic techniques (such as radial endobronchial ultrasonography (rEBUS) and electromagnetic navigation (EMN)) have been developed to reach the peripheral lung but result in small samples. The feasibility of an adequate molecular testing from these specimens has been very little studied.MethodsWe retrospectively reviewed EMN and rEBUS procedures performed in patients diagnosed with lung cancer in our institution in 2017 and 2018. We analysed the sensitivity for rEBUS and EMN and each sampling method, and the feasibility of a comprehensive molecular testing.ResultsIn total, 317 rEBUS and 14 EMN were performed. Median sizes of tumours were 16 and 32 mm for EMN and rEBUS, respectively. Overall sensitivity for rEBUS and EMN was 84.3%. Cytology was found to be complementary with biopsies, with 13.3% of cancer diagnosed on cytology while biopsies were negative. Complication rate was 2.4% (pneumothorax 1.5%, mild haemoptysis 0.9%). Genotyping (immunohistochemistry for ROS1 and ALK followed by fluorescence in situ hybridisation if positive and hybrid capture next-generation sequencing covering 48 genes), when ordered (n=188), was feasible in 69.1% (EGFR 17.7%, KRAS 31.7%, BRAF 4.8%, ALK 1.2%, MET 3.1%, HER2 0.8%). PD-L1 (programmed death-ligand 1) expression, when ordered (n=232), could be analysed in 94% of cases. Overall, 56.9% (33 out of 58) of patients for whom genotyping was not feasible underwent a second sampling (12 pretreatment, 21 at progression), allowing for the detection of six actionable genotypes (five EGFR, one MET).ConclusionrEBUS and EMN are sensitive and safe procedures that result in limited samples, often not suitable for genotyping, highlighting the importance of integrating liquid biopsy in routine testing.

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.