[Navigational bronchoscopy with tranbronchial cryobiopsy in differential diagnosis of peripheral pulmonary lesions]. / Navigatsionnaya bronkhoskopiya s transbronkhial'noi kriobiopsiei v differentsial'noi diagnostike perifericheskikh obrazovanii legkikh.

OBJECTIVE: To evaluate the efficacy and safety of tranbronchial cryobiopsy (TBCB) with 1.9-mm and 1.1-mm cryoprobes in patients with peripheral pulmonary lesions (PPLs). MATERIAL AND METHODS: We analyzed 34 patients (mean age 60 years) with PPLs who underwent bronchoscopy with TBCB. Mean lesion size was 31.5 mm, upper lobe localization was predominant (47% of cases). CT signs of appropriate bronchus were identified in 79% (27/34) of cases. Manual branch tracking and virtual bronchoscopy (VB) were performed pre-procedurally, and radial endobronchial ultrasonography (rEBUS) was performed during bronchoscopy for accurate positioning of PPLs. TBCB was performed using 1.9-mm (n=19) or 1.1-mm (n=15) cryoprobes without fluoroscopic guidance. Incidence and severity of bleeding and pneumothorax were evaluated in all patients. RESULTS: Total efficacy of TBCB was 76.5% (26/34): 78.9% (15/19) for 1.9-mm cryoprobe and 73.3% (11/15) for 1.1-mm cryoprobe (p=0.702). Efficacy depended on the presence of CT signs of bronchus (presence - 94%, absence 14.3%, p<0.001) and PPL size (94% for PPL >30 mm and 58.8% for PPL <30 mm, p=0.016). Central probe position during rEBUS was associated with 94.7% diagnostic efficacy (18/19), adjacent probe position - 72.7% (8/11) (p=0.088). Bleeding grade 3 (Nasville) occurred in 5.8% (2/34) of cases, and no pneumothorax was observed. CONCLUSION: TBCB is an effective and safe diagnostic method for PPLs.

Use of the Archimedes navigation system to diagnose peripheral pulmonary lesions: preliminary Italian results.

Diagnosis of peripheral pulmonary lesions (PPL) is one of the most challenging fields in early lung cancer diagnosis. Despite novel techniques and new approaches to the periphery of the lung, almost 25% of PPL remains undiagnosed. Virtual bronchoscopy navigation (VBN) potentially allows to sample PPL previously not reachable with conventional bronchoscopy. In this preliminary report, we described nine cases of PPL (in which conventional bronchoscopy did not reach the lesion) sampled with VBN, from which we obtained a diagnosis in seven out of nine cases (77.8%), consistent with other reported results in literature. More large-scale data are needed to whether VBN can increase diagnostic yield (DY) of PPL.

Diagnostic outcomes of radial endobronchial ultrasound bronchoscopy guided by manual navigation in the evaluation of peripheral pulmonary lesions: An observational study.

BACKGROUND AND AIMS: Manual navigation (MN), drawing a bronchoscopic road map simply by looking at the consecutive computed tomography (CT), is feasible and economical. However, scant data about the use of MN in radial endobronchial ultrasound (r-EBUS) bronchoscopy have been documented till now. We aimed to evaluate the diagnostic performance of r-EBUS bronchoscopy guided by MN for diagnosing peripheral pulmonary lesions (PPLs) and to determine clinical factors affecting the diagnostic yield. METHODS: We performed a retrospective, cohort study of consecutive patients with PPLs who underwent r-EBUS bronchoscopic biopsy via guidance of MN from May 2020 to June 2021 in our Respiratory Endoscopic Division. The overall diagnostic yield of MN-guided r-EBUS, the factors affecting the yield, and the diagnostic performance for malignancy were evaluated. RESULTS: A total of 102 patients (103 lesions) were evaluated. The overall diagnostic yield of MN-guided r-EBUS was 82.0%, and it ranged from 79.6% to 82.5%, assuming the undermined cases were all positive cases (79.6%) or negatives (82.5%). The sensitivity of MN-guided r-EBUS for malignancy was 71.4%, ranging from 68.2% to 71.4%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 67.3%, ranging from 63.8% to 69.0%. The multivariate logistic regression showed that "bronchus sign on CT" was the only predictor of the overall diagnostic yield (odds ratio = 11.5, 95% confidence interval: 1.9-70.9, P = 0.009). CONCLUSIONS: MN-guided r-EBUS is feasible in diagnosing PPLs, especially for lesions with bronchus sign on CT.

Transbronchial Cryobiopsy Using the Ultrathin 1.1-mm Cryoprobe with Ultrathin Bronchoscopy under Radial Endobronchial Ultrasound Guidance for Diagnosis of Peripheral Pulmonary Lesions.

INTRODUCTION: Today, the increasing number of incidentally detected peripheral pulmonary lesions (PPLs) within and outside lung cancer screening trials is a diagnostic challenge. This fact encourages further improvement of diagnostic procedures to increase the diagnostic yield of transbronchial biopsy, which has been shown to have a low complication rate. The purpose of this study was to evaluate the safety and feasibility of a new ultrathin 1.1 cryoprobe that can be placed through an ultrathin bronchoscope (UTB) using fluoroscopy and radial endobronchial ultrasonography (rEBUS) navigation for assessing PPLs. METHODS: Thirty-five patients with PPL less than 4 cm in diameter were prospectively enrolled to receive transbronchial cryobiopsies (TBCBs) using the ultrathin 1.1-mm cryoprobe. Navigation to the PPL was accomplished with the UTB. Under rEBUS and fluoroscopy guidance up to 4 cryobiopsies were obtained. The sample sizes of the biopsies were compared to a historic collective derived from a 1.9-mm cryoprobe and standard forceps. The feasibility and safety of the procedure, the cumulative and overall diagnostic yield, and the cryobiopsy sizes were evaluated. RESULTS: After detection with the rEBUS, TBCB was collected from 35 PPLs, establishing a diagnosis in 25 cases, corresponding to an overall diagnostic yield of 71.4%. There was no difference in diagnostic yield for PPL <20 mm or ≥20 mm. All cryobiopsies were representative with a mean tissue area of 11.9 ± 4.3 mm2, which was significantly larger compared to the historic collective (p = 0.003). Six mild and four moderate bleeding events and 1 case of pneumothorax were observed. CONCLUSIONS: Using the ultrathin 1.1-mm cryoprobe combined with an UTB for rEBUS-guided TBCB of PPL is feasible and safe. This diagnostic approach improves bronchoscopic techniques for diagnosing peripheral lung lesions and may contribute to improve diagnosis of lung cancer even in small PPL.

Robotic-assisted bronchoscopy for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis.

Robotic-assisted bronchoscopy (RAB) is a newly developed bronchoscopic technique for the diagnosis of peripheral pulmonary lesions (PPLs). The objective of this meta-analysis was to analyze the diagnostic yield and safety of RAB in patients with PPLs. Five databases (PubMed, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov) were searched from inception to April 2023. Two independent investigators screened retrieved articles, extracted data, and assessed the study quality. The pooled diagnostic yield and complication rate were estimated. Subgroup analysis was used to explore potential sources of heterogeneity. Publication bias was assessed using funnel plots and the Egger test. Sensitivity analysis was also conducted to assess the robustness of the synthesized results. A total of 725 lesions from 10 studies were included in this meta-analysis. No publication bias was found. Overall, RAB had a pooled diagnostic yield of 80.4% (95% CI: 75.7%-85.1%). Lesion size of >30 mm, presence of a bronchus sign, and a concentric radial endobronchial ultrasound view were associated with a statistically significantly higher diagnostic yield. Heterogeneity exploration showed that studies using cryoprobes reported better yields than those without cryoprobes (90.0%, 95% CI: 83.2%-94.7% vs. 79.0%, 95% CI: 75.8%-82.2%, p < 0.01). The pooled complication rate was 3.0% (95% CI: 1.6%-4.4%). In conclusion, RAB is an effective and safe technique for PPLs diagnosis. Further high-quality prospective studies still need to be conducted.

Robotic versus Electromagnetic bronchoscopy for pulmonary LesIon AssessmeNT: the RELIANT pragmatic randomized trial.

BACKGROUND: Robotic-assisted bronchoscopy has recently emerged as an alternative to electromagnetic navigational bronchoscopy for the evaluation of peripheral pulmonary lesions. While robotic-assisted bronchoscopy is proposed to have several advantages, such as an easier learning curve, it is unclear if it has comparable diagnostic utility as electromagnetic navigational bronchoscopy. METHODS: Robotic versus Electromagnetic bronchoscopy for pulmonary LesIon AssessmeNT (RELIANT) is an investigator-initiated, single-center, open label, noninferiority, cluster randomized controlled trial conducted in two operating rooms at Vanderbilt University Medical Center. Each operating room (OR) is assigned to either robotic-assisted or electromagnetic navigational bronchoscopy each morning, with each OR day considered one cluster. All patients undergoing diagnostic bronchoscopy for evaluation of a peripheral pulmonary lesion in one of the two operating rooms are eligible. Schedulers, patients, and proceduralists are blinded to daily group allocations until randomization is revealed for each operating room each morning. The primary endpoint is the diagnostic yield defined as the proportion of cases yielding lesional tissue. Secondary and safety endpoints include procedure duration and procedural complications. Enrolment began on March 6, 2023, and will continue until 202 clusters have been accrued, with expected enrolment of approximately 400 patients by the time of completion in March of 2024. DISCUSSION: RELIANT is a pragmatic randomized controlled trial that will compare the diagnostic yield of the two most commonly used bronchoscopic approaches for sampling peripheral pulmonary lesions. This will be the first known cluster randomized pragmatic trial in the interventional pulmonology field and the first randomized controlled trial of robotic-assisted bronchoscopy. TRIAL REGISTRATION: ClinicalTrials.gov registration (NCT05705544) on January 30, 2023.

Diagnostic Yield vs Diagnostic Accuracy for Peripheral Lung Biopsy Evaluation: Evidence Supporting a Future Pragmatic End Point.

BACKGROUND: Diagnostic yield and accuracy endpoints have been used inconsistently in the evaluation of advanced diagnostic bronchoscopy devices and techniques, limiting between-study comparisons. In addition, diagnostic accuracy can be adjudicated only after prolonged clinical follow-up, which delays reporting on the performance of novel devices. RESEARCH QUESTION: Will a conservative diagnostic yield definition result in few false-negative initial results to closely approximate diagnostic accuracy and represent a useful outcome for future studies of diagnostic utility? METHODS: Commonly used definitions of diagnostic yield were applied to a prospective data set of consecutive peripheral pulmonary lesions sampled by navigational bronchoscopy from 2017 to 2019. All consider malignancy to be diagnostic but differ in their classification of nonmalignant biopsy findings, which were subcategorized as specific benign, nonspecific benign, or normal lung. Diagnostic yield calculations were also compared with diagnostic accuracy, defined as the proportion of biopsy specimens deemed diagnostic by each definition that were confirmed accurate through 2 years of follow-up. RESULTS: A total of 450 biopsy specimens of lesions were analyzed. The prevalence of malignancy was 60.9% (274 of 450). On initial bronchoscopy pathology, there were 227 malignant diagnoses (50.4%), with a single false positive (0.4%). Among 104 biopsy specimens with specific benign findings, only two were false negative for malignancy (1.9%). There were 119 nonspecific benign biopsy specimens, with 46 false negatives for malignancy (38.7%). The discrepancy between diagnostic yield and accuracy was 0.7% for the conservative definition, which only considered malignant or specific benign findings as diagnostic. INTERPRETATION: A conservative diagnostic yield definition excluding nonspecific benign diagnoses closely approximated diagnostic accuracy through 2 years' follow-up, with a less than 1% discrepancy. Using this conservative yield definition may allow for dissemination of reliable diagnostic utility data without protracted delays needed for follow-up data in this era of rapid technological change in advanced diagnostic bronchoscopy.

Robotic versus Electromagnetic Bronchoscopy for Pulmonary LesIon AssessmeNT: the RELIANT pragmatic randomized trial.

Background: Robotic assisted bronchoscopy has recently emerged as an alternative to electromagnetic navigational bronchoscopy for the evaluation of peripheral pulmonary lesions. While robotic assisted bronchoscopy is proposed to have several advantages, such as an easier learning curve, it is unclear if it has comparable diagnostic utility as electromagnetic navigational bronchoscopy. Methods: Robotic versus Electromagnetic Bronchoscopy for Pulmonary LesIon AssessmeNT (RELIANT) is an investigator-initiated, single-center, open label, noninferiority, cluster randomized controlled trial conducted in two operating rooms at Vanderbilt University Medical Center. Each operating room is assigned to either robotic assisted or electromagnetic navigational bronchoscopy each morning, with each OR day considered one cluster. All patients undergoing diagnostic bronchoscopy for evaluation of a peripheral pulmonary lesion in one of the two operating rooms are eligible. Schedulers, patients and proceduralists are blinded to daily group allocations until randomization is revealed for each operating room each morning. The primary endpoint is the diagnostic yield defined as the proportion of cases yielding lesional tissue. Secondary and safety endpoints include procedure duration and procedural complications. Enrolment began on March 6, 2023, and will continue until 202 clusters have been accrued, with expected enrolment of approximately 400 patients by the time of completion in March of 2024. Discussion: RELIANT is a pragmatic randomized controlled trial that will compare the diagnostic yield of the two most commonly used bronchoscopic approaches for sampling peripheral pulmonary lesions. This will be the first known cluster randomized pragmatic trial in the interventional pulmonology field and the first randomized controlled trial of robotic assisted bronchoscopy. Trial registration: ClinicalTrials.gov registration (NCT05705544) on January 30, 2023.

Diagnostic Utility and Safety of Non-Intubated Cryobiopsy Technique Using a Novel Ultrathin Cryoprobe in Addition to Conventional Biopsy Techniques for Peripheral Pulmonary Lesions.

BACKGROUND: Transbronchial cryobiopsy enables high-quality sample collection around the probe tip. Meanwhile, existing cryoprobes have less flexibility and a higher risk of bleeding. The ultrathin cryoprobe with a 1.1-mm diameter addresses these problems and allows specimens to be directly retrieved through the working channel of a thin bronchoscope. OBJECTIVE: This study evaluated the diagnostic utility and safety of non-intubated cryobiopsy using an ultrathin cryoprobe added to conventional biopsy for diagnosing peripheral pulmonary lesions (PPLs). METHODS: The data of patients who underwent conventional biopsy followed by non-intubated cryobiopsy to retrieve specimens through the thin bronchoscope's working channel for diagnosing PPLs at Osaka Metropolitan University Hospital from July 2021 to June 2022 were retrospectively collected. They were analyzed to evaluate the diagnostic utility and safety of adding non-intubated cryobiopsy to conventional biopsy for PPLs. The characteristics of PPLs that obtain additional diagnostic benefits from cryobiopsy over conventional biopsy were also investigated. RESULTS: The analysis included 113 patients. The diagnostic yields of conventional biopsy and non-intubated cryobiopsy were 70.8% and 82.3%, respectively (p = 0.009). The total diagnostic yield was 85.8%, higher than conventional biopsy alone (p < 0.001). Although one moderate bleeding occurred, no severe complications developed. The additional diagnostic benefits of non-intubated cryobiopsy over conventional biopsy were demonstrated when the radial endobronchial ultrasound (R-EBUS) showed "adjacent to" (60.3% vs. 82.8%, p = 0.017). CONCLUSIONS: Non-intubated cryobiopsy using an ultrathin cryoprobe has high diagnostic utility and safety for diagnosing PPLs, with additional diagnostic benefits over conventional biopsy depending on the R-EBUS image.

Computed Tomography Bronchus Sign Subclassification during Radial Endobronchial Ultrasound-Guided Transbronchial Biopsy: A Retrospective Analysis.

The presence of computed tomography bronchus sign (CT-BS) substantially increases the diagnostic yield of peripheral pulmonary lesions. However, the clinical significance of subdividing CT-BS remains controversial. We classified bronchus types on CT into six subtypes (CT-BS group I: types Ia-Ic with the bronchus connected within the lesion, group II: types IIa-IIc without connection) to clarify the differences in their characteristics and investigate the factors associated with diagnosis during radial endobronchial ultrasound (rEBUS)-guided bronchoscopy. In total, 1021 cases were analyzed. Our findings in diagnostic yields were that in CT-BS group I, penetrating type Ic was inferior to obstructed type Ia and narrowing type Ib (59.0% vs. 80.0% and 76.3%, p < 0.001, p = 0.004); in CT-BS group II, compressed type IIa showed no difference when compared with invisible type IIb and uninvolved type IIc (IIa: 52.8% vs. IIb: 46.3% and IIc: 35.7%, p = 0.253). Multivariable analysis revealed that bronchus type (types Ia and Ib vs. Ic) was a significant independent predictor of successful diagnosis in CT-BS group I (odds ratio, 1.78; 95% confidence interval, 1.04-3.05; p = 0.035), along with known factors such as rEBUS visualization. CT-BS subclassification may provide useful information regarding the bronchoscopic technique to facilitate accurate diagnosis.

Diagnostic efficacy of cryobiopsy for peripheral pulmonary lesions: A propensity score analysis.

OBJECTIVES: Recently introduced cryobiopsy can provide quantitatively and qualitatively excellent specimens. However, few studies have directly compared the diagnostic yield of cryobiopsy for peripheral pulmonary lesions (PPLs) with that of conventional sampling methods. MATERIAL AND METHODS: We retrospectively reviewed data from consecutive patients who underwent diagnostic bronchoscopy using radial endobronchial ultrasound and virtual bronchoscopic navigation for PPLs (October 2015 to September 2020). Patients who underwent cryobiopsy were assigned to the cryo group, whereas those who did not undergo cryobiopsy were assigned to the conventional group. The diagnostic outcomes of both groups were compared using propensity score analyses. RESULTS: A total of 2,724 cases were identified, including 492 and 2,232 cases in the cryo and conventional groups, respectively. Propensity scoring was performed to match baseline characteristics, and 481 pairs of cases were selected for each matched group (m-group). The diagnostic yield was significantly higher in the m-cryo group than in the m-conventional group (89.2% vs. 77.6%, odds ratio [OR] = 2.36 [95% confidence interval [CI] = 1.65-3.38], P < 0.001). Propensity score stratification (OR = 2.35 [95% CI = 1.71-3.23]) and regression adjustment (OR = 2.54 [95% CI = 1.83-3.52]) also demonstrated the diagnostic advantages of cryobiopsy. The subgroup analysis revealed that cryobiopsy was notably effective for lesions in the middle lobe/lingula, right/left lower lobe, lesions with ground-glass opacity, and lesions invisible on chest radiography. Although there were more cases of grade 2 and 3 bleeding in the m-cryo group than in the m-conventional group (38.0% vs. 10.2% and 1.5% vs. 0.8%, respectively; P < 0.001), no grade 4 bleeding was observed. CONCLUSION: The propensity score analyses revealed that cryobiopsy was associated with a higher diagnostic yield for PPLs than conventional sampling methods. However, increased bleeding risk should be noted as a potential complication.

Comparison of Ultra-Magnifying Endocytoscopic and Hematoxylin-Eosin-Stained Images of Lung Specimens.

Endocytoscopy enables real-time observation of lesions at ultra-magnification. In the gastrointestinal and respiratory fields, endocytoscopic images are similar to hematoxylin-eosin-stained images. This study aimed to compare the nuclear features of pulmonary lesions in endocytoscopic and hematoxylin-eosin-stained images. We performed an endocytoscopy to observe resected specimens of normal lung tissue and lesions. Nuclear features were extracted using ImageJ. We analyzed five nuclear features: nuclear number per area, mean nucleus area, median circularity, coefficient of variation of roundness, and median Voronoi area. We conducted dimensionality reduction analyses for these features, followed by assessments of the inter-observer agreement among two pathologists and two pulmonologists to evaluate endocytoscopic videos. We analyzed the nuclear features of hematoxylin-eosin-stained and endocytoscopic images from 40 and 33 cases, respectively. Endocytoscopic and hematoxylin-eosin-stained images displayed a similar tendency for each feature, despite there being no correlation. Conversely, the dimensionality reduction analyses demonstrated similar distributions of normal lung and malignant clusters in both images, thus differentiating between the clusters. The diagnostic accuracy of the pathologists was 58.3% and 52.8% (κ-value 0.38, fair), and that of the pulmonologists was 50% and 47.2% (κ-value 0.33, fair). The five nuclear features of pulmonary lesions were similar in the endocytoscopic and hematoxylin-eosin-stained images.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions.

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Efficacy of Radial Endobronchial Ultrasound (R-EBUS) guided transbronchial cryobiopsy for peripheral pulmonary lesions (PPL...s): A systematic review and meta-analysis.

BACKGROUND: Transbronchial lung cryobiopsy (TBLC) is frequently described for the diagnosis of diffuse parenchymal lung diseases (DPLD). A few studies have reported transbronchial cryobiopsy for the diagnosis of peripheral pulmonary lesions (PPL...s). We aimed to study the utility and safety of transbronchial cryobiopsy for the diagnosis of PPL...s. METHODS: We performed a systematic search of the PubMed and Embase databases to extract the relevant studies. We then performed a meta-analysis to calculate the diagnostic yields of transbronchial cryobiopsy and bronchoscopic forceps biopsy. RESULTS: Following a systematic search, we identified nine relevant studies (300 patients undergoing cryobiopsy). All used Radial Endobronchial Ultrasound (R-EBUS) for PPL localization. The pooled diagnostic yield of transbronchial cryobiopsy was 77% (95% CI, 71%...84%) (I^2=38.72%, p=0.11). The diagnostic yield of forceps biopsy was 72% (95% CI, 60%...83%) (I^2=78.56%, p<0.01). The diagnostic yield of cryobiopsy and forceps biopsy was similar (RR 1.05, 95% CI 0.96...1.15), with a 5% risk difference for diagnostic yield (95% CI, ...6% to 15%). There was significant heterogeneity (I^2=57.2%, p=0.017), and no significant publication bias. One severe bleeding and three pneumothoraxes requiring intercostal drain (ICD) placement (major complication rate 4/122, 1.8%) were reported with transbronchial cryobiopsy. CONCLUSIONS: R-EBUS guided transbronchial cryobiopsy is a safe and efficacious modality. The diagnostic yields of TBLC and forceps biopsy are similar. More extensive multicentre randomized trials are required for the further evaluation and standardization of transbronchial cryobiopsy for PPL...s.

Shape-Sensing Robotic-Assisted Bronchoscopy vs Digital Tomosynthesis-Corrected Electromagnetic Navigation Bronchoscopy: A Comparative Cohort Study of Diagnostic Performance.

BACKGROUND: Electromagnetic navigational bronchoscopy has been the dominant bronchoscopic technology for targeting small peripheral lesions and now includes digital tomosynthesis-electromagnetic navigational bronchoscopy (DT-ENB), allowing near-real-time intraprocedural nodule visualization. Shape-sensing robotic-assisted bronchoscopy (ssRAB), with improved catheter stability and articulation recently became available. Although the diagnostic performance of these two methods seems higher than that of legacy systems, data remain limited. We sought to compare the diagnostic yield of these two novel platforms after their introduction at our institution. RESEARCH QUESTION: Does the diagnostic yield of ssRAB differ significantly from that of DT-ENB in patients undergoing biopsy of peripheral pulmonary lesions (PPLs)? STUDY DESIGN AND METHODS: This retrospective comparative cohort study analyzed prospectively collected data on consecutive procedures performed with DT-ENB and ssRAB in their first 6 months of use at our institution. Biopsies were considered diagnostic if histopathologic analysis revealed malignancy or specific benign features that readily explained the presence of a PPL. Nonspecific inflammation, normal lung or airway, and atypia not diagnostic of malignancy were considered nondiagnostic. RESULTS: SSRAB was used to biopsy 143 PPLs in 133 patients and DT-ENB was used to biopsy 197 PPLs in 170 patients. Diagnostic yield was 77% for ssRAB (110 of 143 PPLs) and 80% (158 of 197 PPLs) for DT-ENB (OR, 0.8; 95% CI, 0.5-1.4; P = .4). Median lesion diameters were 17 and 19 mm, respectively. No difference in diagnostic yield was found after adjustment for lesion size, bronchus sign, peripheral vs middle third location, and sex. Pneumothorax complicated 1.5% of ssRAB and 1.8% of DT-ENB procedures (P = .86). INTERPRETATION: SSRAB and DT-ENB showed comparable diagnostic yields and safety profiles in this comparative cohort study.

Value of adding ultrathin bronchoscopy to thin bronchoscopy for peripheral pulmonary lesions: A multicentre prospective study.

BACKGROUND AND OBJECTIVE: The diagnostic yield of thin bronchoscopy with radial probe endobronchial ultrasound (rEBUS) of peripheral pulmonary lesions into which the rEBUS probe cannot be inserted is unsatisfactory. In such cases, adding ultrathin bronchoscopy may be an option. We evaluated the efficacy of sequential ultrathin bronchoscopy for peripheral pulmonary lesions into which the rEBUS probe could not be inserted during thin bronchoscopy. METHODS: In this multicentre prospective study, patients with peripheral pulmonary lesions ≤30 mm in diameter underwent rEBUS-guided transbronchial biopsy using a 4.0 mm diameter thin bronchoscope. In patients with lesions into which a rEBUS probe could not be inserted using that bronchoscope, bronchoscopy using a 3.0 mm diameter ultrathin bronchoscope was performed. RESULTS: A total of 342 patients were enrolled and 340 were analysed. Among them, 87 patients with lesions of a median longest diameter of 17.5 mm underwent thin bronchoscopy followed by ultrathin bronchoscopy. Of the 87 patients, the rEBUS probe was successfully inserted into the lesions via the ultrathin bronchoscope in 50 patients (57.5%). Of the 87 patients, the diagnostic yields of thin bronchoscopy and ultrathin bronchoscopy were 12.6% (11 of 87) and 41.4% (36 of 87), respectively (p < 0.001). CONCLUSION: Ultrathin bronchoscopy affords a higher diagnostic yield for lesions into which a rEBUS probe cannot be inserted via a thin bronchoscope.

A Diagnostic Predictive Model of Bronchoscopy with Radial Endobronchial Ultrasound for Peripheral Pulmonary Lesions.

BACKGROUND: Several factors have been reported to affect the diagnostic yield of bronchoscopy with radial endobronchial ultrasound (R-EBUS) for peripheral pulmonary lesions (PPLs). However, it is difficult to accurately predict the diagnostic potential of bronchoscopy for each PPL in advance. OBJECTIVES: Our objective was to establish a predictive model to evaluate the diagnostic yield before the procedure. METHOD: We retrospectively analysed consecutive patients who underwent diagnostic bronchoscopy with R-EBUS between April 2012 and October 2015. We assessed the factors that were predictive of successful bronchoscopic diagnosis of PPLs with R-EBUS using a multivariable logistic regression model. The accuracy of the predictive model was evaluated using the receiver operator characteristic area under the curve (ROC AUC). Internal validation was analysed using 10-fold stratified cross-validation. RESULTS: We analysed a total of 1,634 lesions; the median lesion size was 25.0 mm. Of these, 1,138 lesions (69.6%) were successfully diagnosed. In the predictive logistic model, significant factors affecting the diagnostic yield were lesion size, lesion structure, bronchus sign, and visible on chest X-ray. The predictive model consisted of seven factors: lesion size, lesion lobe, lesion location from the hilum, lesion structure, bronchus sign, visibility on chest X-ray, and background lung. The ROC AUC of the predictive model was 0.742 (95% confidence interval: 0.715-0.769). Internal validation using 10-fold stratified cross-validation revealed a mean ROC AUC of 0.734. CONCLUSIONS: The predictive model using the seven factors revealed a good performance in estimating the diagnostic yield.

Comparison of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance measurement versus with guide sheath in diagnosing peripheral pulmonary lesions with a diameter ≥3 cm by thin bronchoscope.

OBJECTIVE: This study aims to explore the diagnostic values of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance (rEBUS-D-TBLB) measurement and with guide sheath (rEBUS-GS-TBLB) for peripheral pulmonary lesions (PPLs) with a diameter ≥3 cm by thin bronchoscope. PATIENTS AND METHODS: Six hundred and three patients with PPL (diameter ≥3 cm) were enrolled in this study. The subjects were divided into the rEBUS-D-TBLB and rEBUS-GS-TBLB groups by the random number table method. Patients were assigned to undergo rEBUS-D-TBLB or rEBUS-GS-TBLB, respectively. The histopathology, positive diagnosis rates, duration of the procedure, and postoperative adverse effects between the two groups were examined. RESULTS: A total of 569 patients were included in this study according to the inclusion and exclusion criteria, with 282 cases in the rEBUS-D-TBLB group and 287 cases in the rEBUS-GS-TBLB group. For malignant diseases, the positive diagnosis rates of PPL in the outer/inner-middle lung bands and the right-upper/-lower lung lobes by rEBUS-D-TBLB were noninferior to those of rEBUS-GS-TBLB. The duration of the procedure of rEBUS-D-TBLB was longer than that of rEBUS-GS-TBLB. There were 14 cases of hemorrhage >50 mL, 1 case of postoperative chest pain in the rEBUS-D-TBLB group, and 3 cases of hemorrhage >50 mL in the rEBUS-GS-TBLB group. CONCLUSION: REBUS-D-TBLB by thin bronchoscope has a high diagnostic value for PPL with a diameter ≥3 cm, which may be considered a useful alternative for rEBUS-GS-TBLB in the clinic.

Diagnostic value of a new cryoprobe for peripheral pulmonary lesions: a prospective study.

BACKGROUND: Cryobiopsy is an established technique that yields larger and higher-quality samples than does a forceps biopsy. However, it remains underutilised in the diagnosis of peripheral pulmonary lesions (PPLs), mainly because of difficulties in handling conventional cryoprobes. A recently introduced single-use cryoprobe with a smaller diameter and more flexibility than conventional ones may improve its diagnostic ability for PPLs. We conducted this prospective study to evaluate the feasibility of transbronchial cryobiopsy in the diagnoses of PPLs, using a new 1.7-mm cryoprobe. METHODS: The study included patients with PPLs less than 30 mm in diameter scheduled to undergo bronchoscopy. All the procedures were performed using a combination of virtual bronchoscopic navigation, radial endobronchial ultrasound (R-EBUS) and X-ray fluoroscopy, and all the samples were collected using the cryoprobe alone. Thereafter, we assessed the diagnostic outcomes and safety profiles. RESULTS: A total of 50 patients were enrolled and underwent cryobiopsy. The median lesion size was 20.8 mm (range, 8.2-29.6 mm), and the negative bronchus sign was seen in 34% of lesions. The diagnostic yield was 94% (95% confidence interval, 83.5-98.8%). A positive bronchus sign had a significantly higher diagnostic yield than did a negative bronchus sign (100% vs. 82.4%; P = 0.035). The yield was achieved regardless of other variables, including lesion size, location, and R-EBUS findings. The major complications were mild and moderate bleeding in 28% and 62% of patients, respectively. Pneumothorax was identified in one patient. CONCLUSION: Transbronchial cryobiopsy using the new 1.7-mm cryoprobe is a feasible procedure that has the potential to increase the diagnostic accuracy for PPLs. TRIAL REGISTRATION: Japan Registry of Clinical Trials, jRCT1032200065. Registered July 8 2020, https://jrct.niph.go.jp/en-latest-detail/jRCT1032200065.

Diagnostic Value of Bronchoscopy for Peripheral Metastatic Lung Tumors.

Although lungs are one of the most frequent sites of metastasis for malignant tumors, little has been reported about the value of bronchoscopy for lung metastases presenting with peripheral pulmonary lesions (PPLs). This retrospective cohort study investigated the diagnostic value of bronchoscopy for peripheral metastatic lung tumors. Consecutive patients who underwent diagnostic bronchoscopy with radial endobronchial ultrasound for PPLs and were finally diagnosed with metastatic lung tumors from April 2012 to March 2019 were included. We analyzed 235 PPLs, with a median size of 18.8 mm. The overall diagnostic yield was 76.6%. In a multivariable analysis, large lesion size (>20.0 mm vs. <20.0 mm: 87.6% vs. 67.7%, p = 0.043, OR = 2.26), inner location (inner 2/3 vs. outer 1/3: 84.8% vs. 69.1%, p = 0.004, OR = 2.79), and visibility on radiography (visible vs. invisible: 83.2% vs. 56.1%, p = 0.015, OR = 3.29) significantly affected the diagnostic yield. Although a positive bronchus sign tended to have a higher yield, no significant difference was observed (81.8% vs. 70.6%, p = 0.063). Only one case of lung abscess was observed, with no serious complications. In conclusion, bronchoscopy is a valuable technique for peripheral metastatic lung tumors, with good diagnostic accuracy and safety.