Virtual Bronchoscopic Navigation System Research Articles

Combined use of the Da Vinci robot system and the LungPoint Virtual Bronchoscopic Navigation system in the management of lung cancer: First Hong Kong experience

AbstractSmall ground‐glass opacity intrapulmonary lesions without preoperative histological diagnosis are difficult to localise in minimal invasive thoracic surgery, especially in robotic‐assisted surgery which has limited haptic feedback. Here we present two cases of using the LungPoint Virtual Bronchoscopic Navigation system for indocyanine green injection to assist with localization during robotic thoracic surgery, which might be a safe and feasible technique for such cases with impalpable lesions with no prior histological proof.

Pilot study of archimedes virtual bronchoscopic navigation system-guided biopsy to diagnose lung nodules in children.

Peripheral pulmonary lesions are uncommon in children. Bronchoscopy is a minimal invasive method to obtain a diagnostic lung biopsy. However, due to the lack of effective guidance methods, the diagnostic efficacy of transbronchial lung biopsy for peripheral solitary pulmonary diseases is still limited. Is the Archimedes virtual bronchoscopic navigation system safe and effective for the diagnosis of peripheral pulmonary lesions in children? This pilot study retrospectively analyzed the clinical features, radiological characteristics, operation processes, intra-and postoperative complications, and pathological results of five children who underwent Archimedes-guided biopsy of peripheral pulmonary lesions in Beijing Children's Hospital from May 2021 to May 2022. The cohort comprised five children (all males) with age of 7.1-15.8 years. A guide sheath was inserted through the bronchoscope under the guidance of Archimedes combined with radial endobronchial ultrasound to complete the biopsy under general anesthesia. The fused fluoroscopy technique was used to reconfirm the location of the forceps prior to biopsy in all children. The forceps reached the lesion under the guidance of the navigation and the samples were collected successfully in all children. Pathological examination of the biopsy specimens showed Epstein-Barr virus infection-related lymphoproliferative disease in one child, pulmonary metastasis of rhabdomyosarcoma in one child, and pulmonary vasculitis in one child; high-throughput sequencing of the biopsy tissue sample identified Mycobacterium tuberculosis (sequence no. 80) in one child and Aspergillus (sequence no. 40) in another child. All five children tolerated the biopsy procedure without developing postoperative complications, such as pneumothorax and hemoptysis. Archimedes-guided bronchoscopic lung biopsy is a feasible and efficient way to diagnose peripheral pulmonary lesions in children with manageable complications.

Efficacy and safety of virtual bronchoscopic navigation with fused fluoroscopy and vessel mapping for access of pulmonary lesions.

Virtual bronchoscopic navigation (VBN) with fused fluoroscopy and vessel mapping provides a point of entry (POE) for puncturing airway wall to biopsy lesions. The study was designed to evaluate the safety and efficacy of this technology to diagnose peripheral pulmonary lesions. It was a prospective, single-arm, multicentre study. Patients underwent lesions biopsy with the Archimedes® VBN System via a POE using one of the two techniques: (1) bronchoscopic transparenchymal nodule access (BTPNA) and (2) guided transbronchial needle aspiration (TBNA). Biopsy yield, sampling yield and diagnostic yield were mainly determined in lesions biopsy attempted. One hundred and thirty patients underwent anaesthesia and constituted the intention-to-treat population. One hundred and four patients with 114 lesions had biopsy attempted. Mean lesion size was 2.4 ± 1.13 cm. Sufficient tissue samples were obtained from 86 lesions with a biopsy yield of 75.4%. Nevertheless, sufficient samples for diagnosis based on histology ± cytology were obtained from 107 lesions with a sampling yield of 93.9%. Follow-up was conducted for more than 1year, with a diagnostic yield of 75.4% and 72.8%, respectively, on high and low estimate with consideration of three lesions without follow-up. Two (1.9%) pneumothoraxes and one (1.0%) mild bleeding occurred. BTPNA and guided TBNA contribute to safe and effective sampling of peripheral pulmonary lesions. A relatively high biopsy yield was obtained independent of the presence or absence of a bronchus sign (BS), and high sampling yield and diagnostic yield were obtained independent of location, lesion size and presence or absence of a BS.

Multi-Dimensional Display of Wang's Lymph Node Map Using Virtual Bronchoscopic Navigation System.

Background: Transbronchial needle aspiration (TBNA) is a classical technique for diagnosing mediastinal-hilar lymph node enlargement. However, the diagnostic value of conventional TBNA (cTBNA) is limited in small lymph nodes. Methods: Here, we generated an innovative multi-dimensional virtual lymph node map on top of Wang’s lymph node map using a Lungpoint Virtual Bronchoscopic Navigation System. Results: The virtual bronchoscopic navigation (VBN) system was combined with computed tomography (CT) images to generate extrabronchial, endobronchial, sagittal, coronal as well as horizontal views of the 11 intrathoracic lymph node stations and their adjacent tissues and blood vessels. We displayed the specific puncture site of each lymph node station. The 11 stations were divided into four groups: right mediastinal stations, left mediastinal stations, central mediastinal stations and hilar stations. Conclusion: The VBN system provides a precise view of the intrabronchial landmarks, which may increase the diagnostic accuracy of intrathoracic lymph node adenopathy and assist bronchoscopists with practicing TBNA.

Diagnostic Yield of the Virtual Bronchoscopic Navigation System Guided Sampling of Peripheral Lung Lesions using Ultrathin Bronchoscope and Protected Bronchial Brush.

The use of an ultrathin bronchoscope (UB) to diagnose peripheral pulmonary lesions is described. A virtual bronchoscopic navigation system was used to direct the ultrathin scope to the nodule. One of the constraints of this technique was the inability to confirm the target lesion position during biopsy by using a conventional linear endobronchial ultrasound probe, since the probe does not fit into a 1.2 mm working channel of this bronchoscope. The aim of the study was to review our institutional experience with the use of a UB for sampling peripheral pulmonary lesions using the transbronchial brush guided by virtual bronchoscopy. We describe a technique wherein we attempt to brush all the visible bronchial sub-segments once the bronchoscope has reached close to the nodule. In total, 52 patients underwent the procedure between 2010 and 2017. A multiplanar computed tomography (CT) scan of the chest was obtained and subsequently uploaded to the Lung Point Virtual bronchoscopy navigation software. The UB was parked close to the lesion. All visible airway branches were then brushed using a protected bronchial brush. The data were retrospectively abstracted from the electronic medical records using standardized forms. A total of 52 lesions (40 solid, 8 part-solid, 3 cavitary, and 1 ground-glass) were sampled using a transbronchial brush (median, 2; range, 1-8). Twenty-four lesions were under 2 cm in size. The overall success rates were 67.3%. The average diameter of nodules was 2.7±1.01 cm; 65% lesions were in the outer-third of the lungs. The cancer-specific sensitivity was 72.5%. The presence of bronchus sign; location of the lesion; and the characteristics, size, and stage of cancer did not have any impact on the diagnostic yield. Virtual bronchoscopy-guided ultrathin bronchoscopy with bronchial brushing is safe and has a diagnostic yield comparable to other described techniques for evaluating peripheral pulmonary nodules.

Intrabronchial display of hilar-mediastinal lymph nodes by virtual bronchoscopic navigation system.

The description of precise intrabronchial positions for the sampling of mediastinal‐hilar lymph nodes is critical to successfully perform conventional transbronchial needle aspiration. Previously published maps of mediastinal‐hilar lymph nodes were primarily drawn based on experts’ experience. We generated a virtual map of the most frequently sampled intrathoracic lymph nodes from an intrabronchial perspective using a virtual bronchoscopic navigation system, to assist with training in conventional transbronchial needle aspiration.

Virtual bronchoscopic navigation without X-ray fluoroscopy to diagnose peripheral pulmonary lesions: a randomized trial

BackgroundTransbronchial biopsy for peripheral pulmonary lesions is generally performed under X-ray fluoroscopy. Virtual bronchoscopic navigation (VBN) is a method in which virtual images of the bronchial route to the lesion are produced based on CT images obtained before VBN, and the bronchoscope is guided using these virtual images, improving the diagnostic yield of peripheral pulmonary lesions. VBN has the possibility of eliminating the need for X-ray fluoroscopy in the bronchoscopic diagnosis of peripheral lesions. To determine whether VBN can be a substitute for X-ray fluoroscopy, a randomized multicenter trial (non-inferiority trial) was performed in VBN and X-ray fluoroscopy (XRF) -assisted groups.MethodsThe non-inferiority margin in the VBN-assisted group compared with the XRF-assisted group was set at 15%. The subjects consisted of 140 patients with peripheral pulmonary lesions with a mean diameter > 3 cm. In the VBN-assisted group, the bronchoscope was guided to the lesion using a VBN system without X-ray fluoroscopy. In the XRF-assisted group, the same bronchoscope was guided to the lesion under X-ray fluoroscopy. Subsequently, in both groups, the lesion was visualized using endobronchial ultrasonography with a guide sheath (EBUS/GS), and biopsy was performed. In this serial procedure, X-ray fluoroscopy was not used in the VBNA group.ResultsThe subjects of analysis consisted of 129 patients. The diagnostic yield was 76.9% (50/65) in the VBN-assisted group and 85.9% (55/64) in the XRF-assisted group. The difference in the diagnostic yield between the two groups was -9.0% (95% confidence interval: -22.3% ~ 4.3%). The non-inferiority of the VBN-assisted group could not be confirmed. The rate of visualizing lesions by EBUS was 95.4% (62/65) in the VBN-assisted group and 96.9% (62/64) in the XRF-assisted group, being high in both groups.ConclusionsOn EBUS/GS, a bronchoscope and biopsy instruments may be guided to the lesions using VBN without X-ray fluoroscopy, but X-ray fluoroscopy is necessary to improve the accuracy of sample collection from lesions. During transbronchial biopsy for peripheral pulmonary lesions, VBN cannot be a substitute for X-ray fluoroscopy.Trial registrationUMIN-CTR (UMIN000001710); registered 16 February 2009.

P1.04-002 Positive Airway Pressure-Enhanced CT to Improve Virtual Bronchoscopic Navigation

A main weakness of virtual bronchoscopic navigation (VBN) is unsuccessful segmentation of distal branches approaching peripheral pulmonary nodules (PPN). CT scan acquisition protocol is pivotal for segmentation covering the utmost periphery. We hypothesize that application of continuous positive airway pressure (CPAP) during CT acquisition could improve visualization and segmentation of peripheral bronchi. The purpose of the present pilot study is to compare quality of segmentations under 4 CT acquisition modes: inspiration (INSP), expiration (EXP) and both with CPAP (INSP-CPAP and EXP-CPAP). In 10 patients 320-detector row CT scans with slice thickness of 0.5 mm were performed in the 4 modes. In first 5 patients a pressure ranging 6-10 cmH2O was applied for 3 min immediately before CT acquisition (CPAP6-10). In following 5 a pressure of 10 cmH2O was applied, followed by 3 min of expiratory maneuvers and non-CPAP acquisitions (CPAP10). Segmentations were obtained and measurements manually calculated with a VBN system (LungPoint, Broncus Technologies, Inc., Mountain View, CA, USA). Comparisons for the inspiratory and expiratory models were made upon main airways area (proximal trachea, distal trachea and main bronchi) and distance of the path to the nodule (DIST-PN). Also, 2 random bronchi per lobe were selected and the number of bifurcations (BIF) and distance (DIST) from carina to the very end of the selected bronchi were manually counted and median calculated. Statistical analyses with R-3.2.3. See table 1. A tendency towards enlargement and improved segmentation of airways is seen with the use of CPAP in both levels of pressure. However, the power of this pilot study is limited and larger studies might be encouraged. Funded by La MaratóTV3-20133510, FIS PI09/90917, DPI2015-65286-R, 2014-SGR-1470, PROD-2014-00065, FUCAP and SEPAR.

Combination of virtual bronchoscopic navigation with conventional transbronchial needle aspiration in the diagnosis of peribronchial pulmonary lesions located in the middle third of the lungs

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is frequently applied to the diagnosis of central airway lesions, and endobronchial ultrasound with a guide sheath (EBUS-GS) is mainly used for the diagnosis of peripheral pulmonary lesions. However, there remains an unmet need to improve the diagnostic yields for peribronchial pulmonary lesions located along the secondary/tertiary and fourth/fifth bronchi (the "middle third zone" of the lungs), which neither EBUS-TBNA nor EBUS-GS can easily approach. A combination of virtual bronchoscopic navigation (VBN) with conventional TBNA was utilized for the cytological diagnosis of 15 patients with small pulmonary lesions (less than 20mm in diameter) in the middle third zone between March 2012 and January 2015 in our respiratory institute. The lesions were traced using the VBN system, and then the VBN was operated and guided by the vision of actual bronchoscopy. The TBNA site was determined by VBN, and the specimens were obtained using conventional TBNA under X-ray fluoroscopy. The diagnosis was made based on the cytological findings of the specimens. Adequate specimens were obtained in 12 (80.0%) of the cases through the novel technique of combining TBNA with VBN in bronchoscopic examinations. Seven out of the ten malignant cases (70.0%) were definitely diagnosed by this procedure. No adverse effects were experienced, except for an acceptable amount of bleeding. The combination of VBN with conventional TBNA was advantageous and safe for the cytological diagnosis of small peribronchial pulmonary lesions in the middle third zone of the lungs.

SU‐C‐BRA‐07: Virtual Bronchoscopy‐Guided IMRT Planning for Mapping and Avoiding Radiation Injury to the Airway Tree in Lung SAbR

Purpose:Post‐treatment radiation injury to central and peripheral airways is a potentially important, yet under‐investigated determinant of toxicity in lung stereotactic ablative radiotherapy (SAbR). We integrate virtual bronchoscopy technology into the radiotherapy planning process to spatially map and quantify the radiosensitivity of bronchial segments, and propose novel IMRT planning that limits airway dose through non‐isotropic intermediate‐ and low‐dose spillage.Methods:Pre‐ and ∼8.5 months post‐SAbR diagnostic‐quality CT scans were retrospectively collected from six NSCLC patients (50–60Gy in 3–5 fractions). From each scan, ∼5 branching levels of the bronchial tree were segmented using LungPoint, a virtual bronchoscopic navigation system. The pre‐SAbR CT and the segmented bronchial tree were imported into the Eclipse treatment planning system and deformably registered to the planning CT. The five‐fraction equivalent dose from the clinically‐delivered plan was calculated for each segment using the Universal Survival Curve model. The pre‐ and post‐SAbR CTs were used to evaluate radiation‐induced segmental collapse. Two of six patients exhibited significant segmental collapse with associated atelectasis and fibrosis, and were re‐planned using IMRT.Results:Multivariate stepwise logistic regression over six patients (81 segments) showed that D0.01cc (minimum point dose within the 0.01cc receiving highest dose) was a significant independent factor associated with collapse (odds‐ratio=1.17, p=0.010). The D0.01cc threshold for collapse was 57Gy, above which, collapse rate was 45%. In the two patients exhibiting segmental collapse, 22 out of 32 segments showed D0.01cc >57Gy. IMRT re‐planning reduced D0.01cc below 57Gy in 15 of the 22 segments (68%) while simultaneously achieving the original clinical plan objectives for PTV coverage and OAR‐sparing.Conclusion:Our results indicate that the administration of lung SAbR can Result in significant injury to bronchial segments, potentially impairing post‐SAbR lung function. To our knowledge, this is the first investigation of functional avoidance based on mapping and minimizing dose to individual bronchial segments.The presenting author receives research funding from Varian Medical Systems, Elekta, and VisionRT.

Hands-Free System for Bronchoscopy Planning and Guidance.

Bronchoscopy is a commonly used minimally invasive procedure for lung-cancer staging. In standard practice, however, physicians differ greatly in their levels of performance. To address this concern, image-guided intervention (IGI) systems have been devised to improve procedure success. Current IGI bronchoscopy systems based on virtual bronchoscopic navigation (VBN), however, require involvement from the attending technician. This lessens physician control and hinders the overall acceptance of such systems. We propose a hands-free VBN system for planning and guiding bronchoscopy. The system introduces two major contributions. First, it incorporates a new procedure-planning method that automatically computes airway navigation plans conforming to the physician's bronchoscopy training and manual dexterity. Second, it incorporates a guidance strategy for bronchoscope navigation that enables user-friendly system control via a foot switch, coupled with a novel position-verification mechanism. Phantom studies verified that the system enables smooth operation under physician control, while also enabling faster navigation than an existing technician-assisted VBN system. In a clinical human study, we noted a 97% bronchoscopy navigation success rate, in line with existing VBN systems, and a mean guidance time per diagnostic site = 52 s. This represents a guidance time often nearly 3 min faster per diagnostic site than guidance times reported for other technician-assisted VBN systems. Finally, an ergonomic study further asserts the system's acceptability to the physician and long-term potential.

Feasibility and Safety of Bronchoscopic Transparenchymal Nodule Access in Canines: A New Real-Time Image-Guided Approach to Lung Lesions

The current approaches for tissue diagnosis of a solitary pulmonary nodule are transthoracic needle aspiration, guided bronchoscopy, or surgical resection. The choice of procedure is driven by patient and radiographic factors, risks, and benefits. We describe a new approach to the diagnosis of a solitary pulmonary nodule, namely bronchoscopic transparenchymal nodule access (BTPNA).In anesthetized dogs, fiducial markers were placed and thoracic CT images acquired. From the CT scan, the BTPNA software provided automatic point-of-entry prescribing of a bronchoscopic path (tunnel) through parenchymal tissue directly to the lesion. The preplanned procedure was uploaded to a virtual bronchoscopic navigation system. Bronchoscopic access was performed through the tunnels created. Proximity of the distal end of the tunnel sheath to the target was measured, and safety was recorded.In four canines, 13 tunnels were created. The average length of the tunnels was 32.3 mm (range, 24.7-46.7 mm). The average proximity measure was 5.7 mm (range, 0.1-12.9 mm). The distance from the pleura to the nearest point within the target was 7.4 mm (range, 0.1-15 mm). Estimated blood loss was <2 mL per case. There were no pneumothoraces.We describe a new approach to accessing lesions in the lung parenchyma. BTPNA allows bronchoscopic creation of a direct path with a sheath placed in proximity to the target, creating the potential to deliver biopsy tools within a lesion to acquire tissue. The technology appears safe. Further experiments are needed to assess the diagnostic yield of this procedure in animals and, if promising, to assess this technology in humans.

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).

Diagnostic yield of combined bronchoscopy and endobronchial ultrasonography, under LungPoint guidance for small peripheral pulmonary lesions

The yield of biopsy performed during bronchoscopy is reduced if the lesion is smaller than 30 mm. We evaluated the performance of a new diagnostic technique combining endobronchial ultrasonography with a guide sheath (EBUS-GS) and a virtual bronchoscopic navigation system, LungPoint (Broncus Technologies, Inc., Mountain View, CA, USA), for the diagnosis of small (≤30 mm) peripheral pulmonary lesions (PPL). Between May 2011 and December 2011, we recruited 68 consecutive patients presenting with a PPL 30 mm or less in diameter determined by chest computed tomography. We used the LungPoint system before bronchoscopy to identify the bronchus into which the bronchoscope should be advanced. We used a thin bronchoscope. EBUS-GS was performed using an endoscope ultrasonography system equipped with a 20-MHz mechanical radial-type probe. We used a guide sheath with an external diameter of 1.95 mm, thin forceps and brushing. The diagnostic yield of the 68 PPL was 77.9%; it was 83.7% and 68.0% for the malignant and benign lesions, respectively. Notably, three cases were diagnosed by transbronchial needle-aspiration cytology alone. Univariate and multivariate analyses showed that the EBUS probe localization was the most significant contributor to successful diagnosis (diagnostic yield: within vs adjacent to the lesion = 92.1% vs 60.0%, respectively; P = 0.004 and P = 0.003, respectively). The combination of EBUS-GS and LungPoint was useful for diagnosing small PPL.

Fluoroscopy-assisted thoracoscopic resection after computed tomography-guided bronchoscopic metallic coil marking for small peripheral pulmonary lesions

To re-evaluate the efficacy of fluoroscopy-assisted thoracoscopic resection after computed tomography (CT)-guided bronchoscopic metallic coil marking (FATS-CM), which was our original method for small peripheral pulmonary lesions. Fifty-eight patients with 63 lesions underwent FATS-CM. A metallic coil was installed in the bronchus nearest to the lesion under CT fluoroscopic guidance with ultrathin bronchoscopy. The virtual bronchoscopic navigation (VBN) system was used in 14 cases. Afterwards, we basically performed wide wedge resection (WWR) using a C-arm-shaped roentgenographic fluoroscope during thoracoscopic surgery initially, and then the final procedure was determined by intraoperative histological diagnosis. Moreover, we prospectively treated ground-glass opacity (GGO) lesions of <20 mm diameter according to our treatment protocol from September 2004. We could install coils in the objective bronchi in all cases. The average time required for the marking procedure was 38.9 (15-120) min. Pneumothorax was recognized in 1 (1.7%) case as a complication, but no fatal complications occurred. We could also install coils for each lesion in 4 cases (9 lesions) with multiple lesions. In 14 cases with the VBN system, the examination time and CT number were significantly reduced (P < 0.05 and <0.001, respectively), compared with those of 40 cases without the VBN system. The average interval between the CM and the operation was 5.6 (0-30) days. We never experienced a case of migration preoperatively. Sixty-two (98.4%) lesions were definitively identified, and WWRs were performed using three trocars in 58 (92.1%) cases during thoracoscopic surgery. Lobectomy was initially performed in only 1 case owing to coil migration. Thirty-seven of 40 cases (92.5%) were in line with the treatment protocol. There were no local-regional recurrences in all cases undergoing WWR. We could prospectively show that our method was suitable to perform WWR with a sufficient margin for small GGO lesions of <20 mm. Moreover, we reconfirmed that the advantages of our method were safety, permitting flexibility in scheduling operations and a high ability to deal with multiple lesions. Additionally, our method became a minimally invasive and mature technique by using a new VBN system.

A Mucosa-associated Lymphoid Tissue Lymphoma of the Lung Diagnosed by Transbronchial Needle Aspiration with a Virtual Bronchoscopic Navigation System

A Mucosa-associated Lymphoid Tissue Lymphoma of the Lung Diagnosed by Transbronchial Needle Aspiration with a Virtual Bronchoscopic Navigation System

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...

Clinical Application of Virtual Bronchoscopic Navigation System for Peripheral Lung Lesions

Transbronchial lung biopsy is an indispensable method for the diagnosis of peripheral lung lesions; however, the diagnostic yield still remains unsatisfactory. Endobronchial ultrasound with guide sheath (EBUS-GS) is an excellent method for the decision of biopsy points and has contributed to improvements in diagnostic yield, but the decision of choosing the proper bronchus depends on the individual ability of each bronchoscopist. To clarify the usefulness of the virtual bronchoscopic navigation system (VBN), we evaluated the diagnostic yield and time required to determine the target lesion. Fifty-seven cases using EBUS-GS with VBN (VBN/EBUS-GS group) and 55 cases using EBUS-GS (EBUS-GS group) were compared. In the VBN/EBUS-GS group, computer software detects the air density in the bronchi from the computed tomography image and imports a detailed virtual Bronchoscopic Image. After inserting the starting position and the peripheral target lesion, the software depicts the most ideal route to the target lesion during the bronchoscopic procedure. EBUS is then used to confirm the accuracy of the route. Diagnostic yield was 84.2% for the VBN/EBUS-GS group and 80.0% for EBUS-GS group. The required time to determine the biopsy position was significantly less in the VBN/EBUS-GS group (5.54 ± 0.57 min in VBN/EBUS-GS group vs. 9.27 ± 0.86 min in EBUS-GS group, P<0.01). In conclusion, VBN proved useful in shortening the time needed to determine the biopsy position.

A Single Center Prospective Study on the Outcome of a Novel Virtual Bronchoscopic Navigation System, LungPoint, in Diagnosis of Pulmonary Lesions and/or Mediastinal/Hilar Lymphadenopathy

PURPOSE: Lung Point Virtual Bronchoscopic Navigation System (LPVBN) is a sophisticated planning and assessment module, with side-by-side visual synchronization of the real-time and virtual airway navigation to the desired target lesion. We evaluated the feasibility, diagnostic yield, and complications of the procedure for diagnosis of pulmonary lesions (including peripheral pulmonary lesions and lesions < 2cm in diameter), mediastinal, and hilar lymphadenopathy.

A virtual bronchoscopic navigation system under X-ray fluoroscopy for transbronchial diagnosis of small peripheral pulmonary lesions

We had reported the utility of virtual bronchoscopic navigation system under CT-guidance for the diagnosis of small peripheral pulmonary lesions (PPLs). This study investigated the efficacy of virtual bronchoscopic navigation system for the diagnosis of small PPLs under X-ray fluoroscopy. We performed bronchoscopy with this system for 94 consecutive patients with 96 PPLs (< or =30mm in longest diameter; mean longest diameter, 16.2mm). A standard bronchoscope was used in 38 cases, and an ultrathin bronchoscope in 58 cases. Virtual bronchoscopic images were reconstructed from helical CT data. All the examinations were performed under X-ray fluoroscopy with virtual bronchoscopic navigation system, we referred both virtual bronchoscopic images and actual bronchoscopic images simultaneously to navigate the bronchoscopic pathway to the PPLs. Specimens for pathological examination were collected by transbronchial biopsy (TBB) and/or brushing. Virtual images accorded well with actual bronchoscopic images. The average total examination time was 24.1+/-7.4min (mean+/-S.D.). The overall diagnostic yields were 62.5% (60 of 96 PPLs), 71.1% (27 of 38 PPLs) with the standard bronchoscope, and 56.9% (33 of 58 PPLs) with the ultrathin bronchoscope. Diagnostic rates were 35%, 61.4% and 94.7% for lesions < or =10, 10-20, and >20mm, respectively. There were eight ground glass opacity (GGO) lesions confirmed only on CT scans; seven cases were pathologically diagnosed. All the examinations were performed safely with no complications. Bronchoscopy with virtual bronchoscopic navigation under X-ray fluoroscopy is useful for the diagnosis of small PPLs.