Target Bronchus Research Articles

P1.16-008 Near-Infrared Fluorescence-Guided Pulmonary Segmentectomy Following Endobronchial Indocyanine Green Injection

Near infrared (NIR) fluorescence-guided pulmonary segmentectomy following endobronchial or intravenous indocyanine green (ICG) administration has been developed and reported. The aim of this study is to prospectively validate the feasibility and safety of NIR fluorescence-guided pulmonary segmentectomy following endobrochial ICG injection using navigational bronchoscopy. Patients who underwent pulmonary segmentectomy were prospectively enrolled in this study. Using preoperative CT datasets a 3D image of target segments was reconstructed for lung volumetry and a bronchial road map was created to determine the bronchus for ICG injection. The ICG concentration was 0.125 mg/mL. Immediately after intubation the ICG was injected into the target bronchi using an ultrathin bronchoscope followed by air flushing to expedite ICG dispersion to the periphery. A NIR thoracoscope (PINPOINT, Novadaq) was used to detect ICG fluorescence and determine intersegmental plane for pulmonary segmentectomy. Usefulness and safety of this technique were evaluated by 1) whether ICG demarcation lines correspond to intersegmental lines expected from pulmonary veins, 2) whether large bronchi and vessels in adjacent segments emerge when dividing intersegmental planes using electrical cautery. The patients were followed up to 1 month after surgery to see if any complication existed. Eight male and 7 female patients with a mean age of 66.5 ± 9.6 years were enrolled. Segmentectomy regions included right S1, S2, S6, S8 and S10 segments, and left S1+2+3, lingular, S6, S8, S9+10, and basilar segments. The average bronchoscopic procedure time was 14.3 ± 8.0 minutes. Vital signs were kept stable before and after the bronchoscopic procedure. The mean injected volume of ICG solution was 21.2 ± 8.8 mL as per a case. In 13 out of 15 cases (86.7%), NIR fluorescence guidance was recognized as effective for pulmonary segmentectomy. Intersegmental plane could not be determined in 2 cases likely due to insufficient air flushing, leading to the failure of ICG dispersion to the periphery. There were no complications developed intraoperatively. The average operation time was 193 ± 41 minutes, with a mean bleeding of 110 ± 101 mL. The average duration of drainage was 3.1 ± 1.0 days. Recurrent air leakage happened on postoperative day 6 in 1 case. Otherwise, no procedure related adverse event was noted. NIR fluorescence-guided pulmonary segmentectomy following endobrochial ICG injection using navigational bronchoscopy appeared to be safe and feasible. Sufficient air flushing may be the key for clear ICG demarcation of referred segments.

Indocyanine green fluorescence-navigated thoracoscopic anatomical segmentectomy.

To evaluate the feasibility and efficacy of thoracoscopic anatomical segmentectomy (TS-S) using three-dimensional computed tomography (3D-CT) reconstruction and indocyanine green-fluorescence (ICGF) navigation. Twenty TS-S procedures were performed for 15 primary lung cancers and 5 metastatic lung tumors. Preoperatively we evaluated the target segmental pulmonary artery and created a virtual intersegmental plane using 3D-CT reconstruction. Intraoperatively, the target segmental artery and bronchus were divided, and after intravenous systemic injection of indocyanine green (ICG, 0.25 mg/kg), ICGF of the non-target segments (NTS) was observed using infrared thoracoscopy (KARL STORZ Endoskope Japan K.K., Tokyo, Japan). We marked the border between target and NTS with electrocautery and divided the lung parenchyma along this border using electrocautery or staples. Strength of contrast between target and NTS was quantified as contrast index (CI) and compared over time. ICGF provided demarcation of sufficient clarity and duration to mark the lung surface in 19 patients (95%). TS-S was successfully performed in all patients. Mean operative duration was 186 min (90-310 min) and mean blood loss was 30 mL (0-107 mL). Demarcation appeared 20 s (10-100 s) after injection of ICG, and ICGF lasted 180 s (90-300 s). CI peaked 30 s after the appearance of ICGF and decreased over time. Effective contrast continued for 70 s (30-116 s), which was sufficient to mark the line of demarcation. There were no complications attributable to this method. ICGF navigation is a safe and effective technique for TS-S.

Quantitative Assessment of Airway Pathology in Subjects With COPD Using Low-Dose High-Resolution Computed Tomography.

The purpose of this study was to correlate airway parameters of COPD determined by low-dose high-resolution computed tomography (HRCT) with pulmonary function testing (PFT) results. PFT data were collected for subjects with COPD and healthy controls. All subjects received inspiratory and expiratory phase low-dose HRCT. Bronchi in the apical segment of the right upper lobe (RB1), posterior segment of the right lower lobe (RB6), and lower lingual segment of the left upper lobe (LB5) were the target bronchi. Software automatically calculated airway wall area, inner area, and airway wall area percentage (percentage wall area for bronchial external area). A total of 75 COPD and 20 control subjects were included. The subjects with COPD were classified according to COPD stage, with 20 grade I, II, and III subjects, respectively, and 15 grade IV subjects. In COPD grade II, residual volume/total lung capacity was negatively correlated with airway wall area in LB5 (r = -0.51). In COPD grade III, FVC was negatively correlated with airway wall area percentage in LB5 (r = -0.49) but positively correlated with airway wall area in RB6 (r = 0.52); percent-of-predicted FEV1 was negatively correlated with airway wall area percentage in RB1 (r = -0.49); residual volume was negatively correlated with airway wall area (r = -0.47), and total lung capacity was negatively correlated with airway wall area in RB1 (r = -0.52) (all, P < .001). The results of this study suggest that airway parameters in different COPD grades have no uniform tendency of correlation with PFT, but some HRCT parameters are correlated to some PFT parameters.

Endobronchial ultrasonography using a guide sheath technique for diagnosis of peripheral pulmonary lesions.

Endobronchial ultrasonography using a guide sheath (EBUS-GS) is a novel method used for collecting peripheral pulmonary lesion (PPL) samples. EBUS-GS is performed by introducing a guide sheath-covered miniprobe into the target bronchus and then withdrawing the miniprobe after lesion detection, leaving the guide sheath in situ as a working channel for obtaining lesion samples. EBUS-GS can improve PPL diagnosis rates and be used for obtaining specimens for molecular analysis. In this review, we discuss the clinical applications of EBUS-GS, the factors that affect its diagnostic sensitivity, and potential complications. We also compare EBUS-GS with other available diagnostic techniques and discuss the strengths and limitations of this method.

P1.04-005 Efficacy of Photodynamic Therapy Combined with a Guide Sheath Method in Lung Cancer Patients with Endobronchial Stenosis

Photodynamic therapy (PDT) using a second generation of photosensitizier, talaporfin sodium was useful for the curative or palliative treatment of lung cancer. However, it is required for interventional pulmonologist to perform accurate PD-laser irradiation in some lung cancer case. We hypothesized that all-direction type PD-laser probe covered with a guide sheath (GS) (GS-PDT) made it possible to secure its probe and fix its position in the endobronchial lesion, to enhance the effect of PDT by avoiding direct contact with the tumor lesion, thus preventing its probe from contact with blood. We evaluated the efficacy and safety of this irradiation technique for the lung cancer patients with endobronchial stenosis. Before the procedure, we evaluated the extent of tumor lesion by auto-fluorescence video-bronchoscope (BF TYPE-F260, Olympus, Japan). As a photosensitizer, talaporfin sodium (Laserphyrin, Meiji Pharma, Japan) was administered at 40mg/m2 intravenously 6 hours before irradiation. PDT was performed by using video-bronchoscope (EB-530T, FUJI MEDICAL, Japan) to visualize PD-laser light clearly by adjusting FICE（Flexible spectral Imaging Color Enhancement）mode. We irradiated 664nm laser light to the target bronchus with endobronchial stenosis utilizing an all-direction type laser probe covered with a GS (disposable K203 guide sheath kit, Olympus, Japan) at each dose of 100J/cm2 (150mW) for 11 minutes and 7 seconds under fluoroscopic guidance. After one month, we evaluated the endoscopic efficacy of this method. Between December 2014 and April 2015, we performed GS-PDT for three patients with pathologically diagnosed lung cancer, 1 squamous cell carcinoma, 1 adenocarcinoma and 1 small cell carcinoma. Stage IA squamous cell carcinoma patient with endobronchial stenosis underwent definitive therapy. Stage IA adenocarcinoma patient with endobronchial wall spread of tumor to proximal respiratory tract underwent a combination of induction chemo-radiotherapy followed by sleeve left upper lobectomy as for definitive therapy to reduce the extent of lung resection. Stage IIIA limited-stage small-cell lung cancer patient with the stenosis of right main and upper lobe bronchus underwent palliative therapy to improve oxygenation and to prevent obstructive pneumonia. One month after GS-PDT, we confirmed the endoscopic response (1 complete response, 2 partial responses). No PDT-related complications occurred. New GS-PDT method was safe and could be an effective technique to accurately irradiate the lung cancer patients with endobronchial stenosis.

A simple method of bronchial occlusion with silicone spigots (Endobronchial Watanabe Spigot; EWS®) using a curette.

Background:Bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) has been shown to be useful in managing prolonged bronchopleural fistulas and intractable hemoptysis. EWS bronchial occlusion using a curette is less technically demanding. This retrospective study evaluated the clinical utility and simplicity of this method.Methods:A total of 18 consecutive patients (15 men, 3 women, aged 47–85 years) who underwent bronchial occlusion using an EWS from April 2012 to August 2014 were evaluated. The method involves sticking the tip of a curette into an EWS to the first joint, allowing it to be turned in any direction or at any angle. The time required to occlude the target bronchus was measured on routinely recorded digital videos. Other parameters evaluated included success rates, complications, and clinical outcomes.Results:Of the 18 patients, 11 underwent bronchial occlusion for intractable pneumothorax, 5 for postoperative bronchopleural fistula, two for intractable empyema, and one for hemoptysis. Each patient required 1–7 EWSs (median 4). Target bronchi included the right upper (n = 8), left upper (n = 5), right lower (n = 2), left lower (n = 2), and right middle (n = 1) bronchi. The success rate of EWS insertion into the target bronchus was 100%. Time per EWS occlusion ranged from 65–528 sec (median 158.5 sec). Of the 62 insertions, 36 (58.1%) were completed within 3 min, and 58 (93.5%) within 5 min. Successful outcomes were observed in 15 (83.3%) of the 18 patients.Conclusions:EWS bronchial occlusion using a curette is a simple method for managing intractable bronchopleural fistulas in daily clinical settings.

Intrabronchial Infusion of Autologous Blood Plus Thrombin for Intractable Pneumothorax After Bronchial Occlusion Using Silicon Spigots

Background:Bronchial occlusion therapy using silicon spigots is effective for intractable pneumothorax. However, sometimes the pneumothorax is refractory to bronchial occlusion because of collateral ventilation. For such difficult pneumothoraces, we attempted an intrabronchial infusion of autologous blood plus thrombin to control collateral ventilation and stop air leaks.Methods:We performed bronchial occlusions using silicon spigots in patients with spontaneous pneumothorax secondary to emphysema and refractory to chest drainage, but which was inoperable owing to each patient’s poor surgical candidacy and poor overall health condition. When bronchial occlusion proved ineffective, we undertook intrabronchial infusion of autologous blood plus thrombin, 2 to 4 days after bronchial occlusion. A catheter was inserted into the subpleural area, through a gap between the silicon spigot and the bronchial wall, using a flexible bronchoscope under fluoroscopic guidance. Autologous blood, followed by a thrombin solution, was infused using the catheter. We repeated the same infusion a total of 4 to 6 times while changing the target bronchi. All interventions were performed under local anesthesia.Results:The subjects were 9 men, aged from 61 to 88 years, with smoking histories. Three patients also had interstitial pneumonia, and 6 patients had undergone pleurodesis in vain before bronchial occlusion. For 4of the 9 patients, autologous blood plus thrombin infusions successfully stopped air leaks, and in 3 patients, intrabronchial infusions and pleurodesis halted leaks altogether.Conclusion:Intrabronchial infusion of autologous blood plus thrombin was effective for intractable pneumothoraces that could not be clinically managed, even by bronchial occlusion using silicon spigots.

Bronchoscopy for Pulmonary Peripheral Lesions With Virtual Fluoroscopic Preprocedural Planning Combined With EBUS-GS: A Pilot Study.

Virtual fluoroscopic preprocedural planning (VFPP) is a figure in which the trace lines between the trachea and the target lesions are constructed along the connecting bronchus on Ray Summation image similar to fluoroscopy. The lines can be displayed at any angle with 3D imaging. This system was applied to bronchoscopy as a reference for forceps guidance under the fluoroscopy, as a new type of navigation. The objective of this study was to demonstrate the feasibility of VFPP. Patients with pulmonary peripheral lesions (PPLs) with long axis ≤30 mm were recruited. Bronchoscopy with endobronchial ultrasonography with a guide sheath (EBUS-GS) was performed by using simultaneous display of VFPP. For 27 patients with 27 lesions, endobronchial ultrasonography with a guide sheath with simultaneous display of VFPP was performed. The median lesion size was 20.2 mm (range, 10 to 30 mm). The median examination time was 24.5 minutes (range, 12 to 50 min). Diagnosis was made for 17 lesions of the total 27. Lung cancer was diagnosed in 12 lesions, nontuberculous mycobacterial disease in 1 lesion, lymphoid hyperplasia in 1 lesion, and inflammation in 3 lesions. In 10 lesions, no diagnosis was made. The diagnostic rate of the procedure was 63.0%. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for malignant disease were 66.7%, 100%, 45.5%, 100%, and 73.9%, respectively. VFPP was easy to prepare and useful for selecting target bronchi. This study confirms feasibility of the VFPP as an adjunct to minimally invasive transbronchial biopsy of pulmonary peripheral lesions.

How to deal with benign hilar or interlobar lymphadenopathy during video-assisted thoracoscopic surgery lobectomy-firing the bronchus and pulmonary artery together.

Anatomic lung resection for lung cancer by video-assisted thoracoscopic surgery (VATS) has become popular for resectable lung cancer. However, complicated situations with hilar or interlobar lymphadenopathy were tough for surgeons. We'd like to introduce a method of "firing the bronchus and pulmonary artery together" via a video demo demonstration for troubleshooting situations with severe inflammatory or calcified peri-arterial/peri-bronchial lymphadenopathy. The inflammatory and calcified lymph nodes surrounding the target bronchus and artery were firstly dissected via sharp dissection using scissors. There was no clearance between the right lower bronchus and artery, then we fired them together using endo-stapler. At last, the stumps were shortened and reinforced via complementary cross mattress suture. This video shows a classic three portal VATS right lower lobectomy, which was complicated with severe inflammatory and calcified lymph nodes. The operation went through smoothly. The postoperative course of the patient was uneventful. If there was no clearance between the target bronchus and artery during a complicated VATS lobectomy caused by severe lymphadenopathy, firing the bronchus and pulmonary artery together was an optimal option.

Virtual assisted lung mapping: navigational thoracoscopic lung resection

Virtual assisted lung mapping (VAL-MAP) is a new technique for bronchoscopic lung marking developed to assist in navigational lung resection. Unlike conventional marking techniques using a single marking to identify an intrapulmonary tumor, VAL-MAP utilizes multiple dye-mediated markings, providing “geometric information” on the lung surface. The purpose of the technique is to identify a tumor and obtain sufficient resection margins, either in wedge resection or segmentectomies. Computer-based virtual bronchoscopy is used to design the lung map and to identify target bronchi for each marking. The dye injection procedure is conducted using a regular bronchoscope under fluoroscopy followed by a CT scan, which is then reconstructed into 3D images for intraoperative navigation. The advantages of VAL-MAP include: it is a reasonably safe procedure based on experience from approximately 1,300 markings undertaken in >430 patients; the dye lasts without significant fading for 2–3 days; the technique has good reproducibility; and multiple markings and adjustment using post-mapping CT result in the procedure being highly resistant to technical failure. VAL-MAP is likely to benefit many patients and surgeons in the era of minimally invasive navigational-based thoracic surgery. The technique has scope for further development, making it an exciting new field of research in thoracic surgery.

A Novel Technique for the Placement of Endobronchial Watanabe Spigots Into the Bronchus: Side-Grasping Method.

Bronchial occlusion with an endobronchial Watanabe spigot (EWS) is effective for the management of persistent pulmonary air leaks; however, an optimal procedure for placing the spigot at the target bronchus remains debatable. The procedure most currently applied involves grasping the middle of the graspable part of the EWS with grasping forceps (conventional method). In this study, we assess a new technique, the side-grasping method, to maneuver the spigot into the target bronchus by using rotatable biopsy forceps to grasp the edge of the graspable part of the EWS. The aim of this study is to evaluate the effectiveness of this new technique for the simple placement of the EWS. To compare the number of bronchoscopists who were able to place the EWS correctly within 10 minutes, and the time needed to place each spigot for both methods into 4 canine bronchi. More bronchoscopists correctly placed the EWS within 10 minutes using the side-grasping method compared with the conventional method (35/40 vs. 15/40, P<0.01). The total time needed to place spigots into all bronchi using the side-grasping method was 13±2.2 minutes versus 27.8±3.6 minutes using the conventional method (P<0.01). The side-grasping method described in this study was a simple and effective technique for correctly placing an EWS spigot into the target bronchus.

Clinical investigation of detecting the bronchi responsible for pulmonary air leakage by injecting methylene blue saline in 27 cases with intractable pneumothorax and bronchial fistula

To establish a new method for detecting the bronchus responsible for pulmonary air leakage by injecting methylene blue saline and to evaluate its efficacy and safety in cases with intractable pneumothorax and bronchial fistula. From January 2006 to October 2013, a total of 19 cases of intractable spontaneous pneumothorax and 8 cases of bronchial fistula were recruited in the study at the Fourth Hospital affiliated to Hebei Medical University. Of all the cases, 15 were diagnosed as having tension pneumothorax and 12 as having communicating pneumothorax. All the cases failed to respond to continuous pleural suction for more than 5 days and consented to the proposed treatment. Before procedure, chest suction was established to allow sustained airflow through the drainage tube while the patients breathed normally. Under direct vision through fiberoptic bronchoscope, injection catheter was inserted into the bronchoscopy channel, and methylene blue saline was slowly injected into the potentially leaking segmental or sub-segmental bronchi. When a steady decline or disappearance in the amount of methylene blue saline in the airways was observed, or methylthionine-tainted saline was detected within the chest drainage tube, the bronchus responsible for air leakage was indicated. Before blocking the target bronchus, the negative pressure level of pleural suction should be reduced or stopped, and then porcine fibrin glue or a-cyanoacrylate was used for sealing the bronchi associated with air leakage. When the air was absent from the drainage tube, and lung recruitment was indicated in the chest X-ray for 5 days, and bronchial blockade of air leakage was proved successful. The bronchi responsible for air leakage were successfully located in all 27 cases, among them segmental bronchi were located in 16, subsegmental bronchi in 10, and small subsegmental bronchus in only one. Multiple adjacent segmental involvement occurred in 3, and multiple adjacent subsegmental involvement in 5 cases. The average time for locating the target bronchi was (51 ± 9) s, among them the average time for tension pneumothorax was (48 ± 15) s compared with (53 ± 16) s for communicating pneumothorax (t = 0.416, P = 0.699) . The average amount of methylene blue saline consumed for locating the target bronchi was (42 ± 23) ml. During the procedure, the membrane of the bronchi was kept intact, and the vital signs were stable. Blockade of the target bronchi was successful with fibrin glue in 20 cases and with OB glue in 7 cases. A total of 61 times of bronchial blocking were performed, and the airflow of the chest drainage tube was instantly stopped in 17 times, gradually stopped in 10, steadily reduced in 22 and no change in 12 times. Adverse effects included severe cough in 4 cases, fever in 3, pleural hemorrhage in 3, and chest pain, atelectasis, and pneumonia in 2 cases, respectively. The bronchi responsible for pulmonary air leakage in patients with spontaneous pneumothorax and bronchial fistula could be determined by injecting methylene blue saline into the airways. This novel method does not require special instruments, and is easy to perform with a high safety and effectiveness.

Virtual Bronchoscopic Navigation Combined with Ultrathin Bronchoscopy. A Randomized Clinical Trial

In bronchoscopy, an ultrathin bronchoscope can be advanced to more peripheral bronchi. Because virtual bronchoscopic navigation (VBN) is a method to guide a bronchoscope under direct observation using VB images, VBN may be particularly useful when combined with ultrathin bronchoscopy. This prospective multicenter study evaluated the value of VBN-assisted ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions. We randomly assigned 350 patients with peripheral pulmonary lesions (diameter, ≤30 mm) to VBN-assisted or non-VBN-assisted groups. An ultrathin bronchoscope (outer diameter, 2.8 mm) was introduced to the target bronchus using a VBN system in the VBN-assisted group, whereas only computed tomography axial images were referred to in the non-VBN-assisted group. Specimen sampling sites were verified using X-ray fluoroscopy. Subjects for analysis included 334 patients. There was no significant difference in the diagnostic yield between the VBN-assisted group (67.1%) and the non-VBN-assisted group (59.9%; P = 0.173). The subgroup analysis showed that the diagnostic yield was significantly higher in the VBN-assisted group than in the non-VBN-assisted group for right upper lobe lesions (81.3% vs. 53.2%; P = 0.004); lesions invisible on posterior-anterior radiographs (63.2% vs. 40.5%; P = 0.043); and lesions in the peripheral third of the lung field (64.7% vs. 52.1%; P = 0.047). VBN-assisted ultrathin bronchoscopy does not improve the diagnostic yield for peripheral pulmonary lesions. However, the method improves the diagnostic yield for lesions in the subcategories (right upper lobe, invisible, peripheral third), warranting further study. Clinical trial registered with www.umin.ac.jp/ctr/ (UMIN 000001536).

Computed tomography lymphography by transbronchial injection of iopamidol to identify sentinel nodes in preoperative patients with non–small cell lung cancer: A pilot study

The objective of the present study was to assess the safety and feasibility of computed tomography lymphography by transbronchial injection of a water-soluble extracellular computed tomography contrast agent. From April 2010 to May 2011, patients with clinical stage I non-small cell lung cancer who were candidates for lobectomy were enrolled in the present study. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. Computed tomography images of the chest were obtained 0.5 and 5 minutes after 2 or 3 mL of iopamidol was injected through a microcatheter. Sentinel nodes were identified when the maximum computed tomography attenuation value of the lymph nodes on the postcontrast computed tomography images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection. The ultrathin bronchoscope could access the targeted bronchus, and iopamidol was delivered into the peritumoral area in all 13 patients without any complications. Sentinel nodes were identified in 12 (92.3%) of the 13 patients. The average number of sentinel nodes was 1.5 (range, 1-2). Pathologic examination revealed metastatic lymph nodes in 2 patients. Metastatic nodes were included with the sentinel nodes. Computed tomography lymphography by transbronchial injection of iopamidol was a safe and feasible method to identify the sentinel nodes in patients with clinical stage I non-small cell lung cancer.

Virtual bronchoscopic navigation combined with endobronchial ultrasound to diagnose small peripheral pulmonary lesions: a randomised trial

BackgroundBronchoscopy using endobronchial ultrasound (EBUS) can help to diagnose small peripheral pulmonary lesions. However, although biopsy sites can be confirmed, a bronchoscope cannot be guided in EBUS. Virtual bronchoscopic navigation...

Localization of the bronchial air leakage in pneumothorax by injection of human albumin foam

To evaluate the efficacy and safety of a new method to determine the bronchus for air leakage in pneumothorax by injection of human albumin foam. In 29 cases with pneumothorax, the bronchus responsible for air leakage was localized by injecting foam of human albumin into target bronchus under direct view of bronchoscopy. The bronchus for air leakage was successfully localized in all the 29 cases of pneumothorax. The average time for locating (from injection of the foam to the localization of the bronchus) was (4.0 ± 1.2) min, and the average amount of 20% human albumin used was (8.0 ± 2.6) ml for each patient. The air leakage was treated accordingly, and occlusion by fibrin glue was successfully carried out in 21 cases and by OB glue in 8 cases. Severe cough was noted in 6, fever in 4, thoracic bleeding in 4 cases, and chest pain in 1 case. Injection of human albumin foam into target bronchus under bronchoscopy was a simple, safe and effective method for the localization of the bronchus for air leakage in pneumothorax.

LungPoint—A New Approach to Peripheral Lesions

Although flexible bronchoscopy is the least invasive procedure for sampling, it is limited by its inability to reach lesions in the peripheral segments of the lung. Biopsy success is further compromised if the lesion is less than 30 mm in diameter or cannot be seen on fluoroscopy. We wanted to explore whether a new bronchoscopic navigation system could help access the peripheral lung airways and enable lesion sampling. The LungPoint system produced a virtual bronchoscopic pathway indicating the bronchus into which the bronchoscope should be advanced. Virtual bronchoscopic images were displayed alongside and registered with actual bronchoscopic video. After performing broncoscopy with a standard bronchoscope for first examination, the thin bronchoscope was advanced to the target bronchus under direct visualization without fluoroscopy. A pilot study included consecutive patients at a tertiary teaching hospital with pulmonary peripheral lesions (<42 mm). Biopsies were taken later. Study subjects included 25 patients (9 women and 16 men, mean age 67 years) with 25 lesions (mean size 28 mm). Using this navigation system, the bronchoscope could be advanced along the planned route in all cases. In 14 of the cases (56%), the bronchoscope could be advanced all the way to the lesion bronchus. The planning time was a median of 5 minutes, and the median examination time was 15 minutes. A definitive diagnosis was possible in 20 cases (80%). One patient experienced a small pneumothorax because of the biopsy that resolved without drainage. No other complications occurred. This navigation system is useful for bronchoscopy for pulmonary peripheral lesions (NCT01067755).

Changes and Current State of Diagnosis of Lung Cancer After Development of the Flexible Bronchofiberscope

The flexible bronchofiberscope developed by Ikeda et al. has brought about revolutionary changes in the diagnosis and treatment of lung cancer. Advances in this device are continuing to emerge and lesions even smaller than those visible to the naked eye can now be visualized. In addition, the use of ultrasound now enables diagnosis of extramural bronchial lesions. Bronchoscopy is also used for the treatment of early hilar lung cancer, and in patients with airway stenosis due to advanced cancer, laser therapy, brachytherapy, and stenting can be performed. The bronchofiberscope is also very useful for tissue sampling from the lung periphery. Further advances in computed tomography imaging have enabled bronchoscopy under computed tomography fluoroscopy, and virtual bronchoscopy images can be generated from computed tomography imaging. Navigation systems have been developed to show the target bronchus where instruments such as forceps should be guided. Computed tomography imaging has made remarkable advances, and computed tomography now plays a central role in chest imaging, including early detection of lesions by low-dose computed tomography, qualitative diagnosis by high-resolution computed tomography and diagnosis of disease progression by contrast computed tomography. Ikeda et al. introduced the concept of personal health data recording system to manage these various images but the technology was not mature enough at that time for implementation. With modern advances in information technology, this is likely to be realized using an electronic health record system.

Virtual bronchoscopy-guided transbronchial biopsy for aiding the diagnosis of peripheral lung cancer

Objective The aim of this study was to evaluate the clinical value of virtual bronchoscopy (VB) in aiding diagnosis of peripheral lung cancer by transbronchial biopsy (TBB). In addition, we sought to systematically analyze the factors that affect the diagnostic sensitivity of VB-guided TBB for the evaluation of peripheral lung cancers. Materials and methods A hundred and twenty-two peripheral lung cancers from 122 patients (82 men and 40 women, 38–84 years; median 68.5 years) who were performed VB-guided TBB were evaluated retrospectively. VB was reconstructed from 1- or 0.5-mm slice thickness images of multi-detector CT (MDCT). Experienced pulmonologists inserted the conventional and ultrathin bronchoscopes into the target bronchus under direct vision following the VB image. Results A definitive diagnosis was established by VB-guided TBB in 96 lesions (79%). The diagnostic sensitivity of small pulmonary lesions ≤30 mm in maximal diameter (71%) was significantly lower than that of lesions >30 mm (91%, p = 0.008). For small pulmonary lesions ≤30 mm ( n = 76), internal opacity of the lesion was the independent predictor of diagnostic sensitivity by VB-guided TBB, and the non-solid type lung cancers were significantly lower than the solid type and part-solid type lung cancers for diagnostic sensitivity (odds ratio = 0.161; 95% confidence interval = 0.033–0.780; p = 0.023). Conclusion Use of an ultrathin bronchoscope and simulation with VB reconstructed by high quality MDCT images is thought to improve pathological diagnosis of peripheral lung cancers, especially for solid and partly solid types. For small pulmonary lesions ≤30 mm, the lesion internal opacity is a significant factor for predicting the diagnostic sensitivity, and the sensitivity was low for small non-solid type of lung cancers.

Diagnosis of peripheral pulmonary lesions using a bronchoscope insertion guidance system combined with endobronchial ultrasonography with a guide sheath

We developed a bronchoscope insertion guidance system that produces virtual images by extracting the bronchi by automatic threshold adjustment, and searching for the bronchial route to the determined target. We used this system in combination with a thin bronchoscope and endobronchial ultrasonography with a guide sheath (EBUS-GS), and evaluated its practicability, usefulness and safety. The subjects were 31 patients with 32 peripheral pulmonary lesions. Computed tomography (CT) data were transferred into this system, and virtual bronchial images were automatically produced by setting the lesion as the target. While virtual images with the target were displayed for comparison with real images by the system, a thin bronchoscope was advanced to the target bronchus. Transbronchial biopsy (TBB) was then performed by EBUS-GS. The system automatically produced virtual images to a median of fifth- (third- to seventh-) order bronchi. In all patients, the thin bronchoscope could be guided along the planned route, and observation to a median of fifth- (third- to seventh-) order bronchi was possible. Thirty lesions (93.8%) were successfully visualized by EBUS, and 27 (84.4%) could be pathologically diagnosed. In lesions < or =30mm in size, the EBUS visualization yield was 91.7% (22/24), and the diagnostic yield was 79.2% (19/24). The median total examination time was 22.3 (9.8-41.5) min. In summary, using the bronchoscope insertion guidance system, virtual images can be readily produced, and the bronchoscope can be successfully guided to the target. This method is promising as a routine examination method in the biopsy of peripheral pulmonary lesions.