Robot-Assisted Bronchoscopy for Identification of Lung Nodules During Minimally Invasive Pulmonary Resection.

OBJECTIVE: Small pulmonary nodules can be difficult to identify during minimally invasive surgical (MIS) resection. Previous investigators have reported using standard bronchoscopy with electromagnetic navigation to identify small pulmonary nodules. Robot-assisted bronchoscopy has been introduced into clinical practice and has shown utility for the biopsy of small lesions. We report our experience using robot-assisted bronchoscopy with dye marking to aid in minimally invasive pulmonary resection. METHODS: Patients with peripheral pulmonary nodules underwent robot-assisted bronchoscopy before a planned minimally invasive resection. Indocyanine green or methylene blue was injected directly into the targeted lesion. Surgical resection was then immediately performed. Success was defined as dye visualization leading to sublobar resection of the target nodule without the need for lobectomy or thoracotomy. RESULTS: Thirty patients with a single targeted nodule underwent robot-assisted bronchoscopy followed by MIS resection. The median lesion size was 9 mm (4 to 25 mm), and the median distance from the pleura was 5 mm (1 to 32 mm). The success rate was 83.3% (25 of 30). There were 3 cases in which the dye was not visualized, and in 2 cases there was free extravasation of dye. The targeted nodule was identified in these 5 patients without the need for thoracotomy or lobectomy. Pathology revealed non-small cell lung cancer (n = 13, 43.3%), metastatic disease (n = 11, 36.7%), and benign disease (n = 6, 20%). There were no complications related to the use of robot-assisted bronchoscopy. CONCLUSIONS: Robot-assisted bronchoscopy with dye marking is safe and effective for guiding minimally invasive resection of small peripheral pulmonary nodules.

[Clinical Application of Robotic Assisted Bronchoscopy 
in Peripheral Pulmonary Nodule Biopsy].

With the popularization of chest computed tomography (CT) lung cancer screening, the detection rate of peripheral pulmonary nodules is increasing day by day. Some patients could make clear diagnoses and receive early treatment by obtaining biopsy specimens. Transbronchial lung biopsy (TBLB) is one of the non-surgical biopsy methods for peripheral pulmonary nodules, which has less trauma and lower incidence of complications compared to percutaneous thoracic needle biopsy (PTNB). However, the diagnostic rate of TBLB is about 70%, which is still inferior to that of PTNB, which is about 90%. Since 2018, robot assisted bronchoscopy systems have been applied in clinical practice. This article reviews their application in further improving the diagnostic rate of peripheral pulmonary nodules by TBLB.
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Virtual bronchoscopic navigation with intraoperative cone-beam CT for the diagnosis of peripheral pulmonary nodules.

OBJECTIVE: Transbronchial biopsy is a safe manner with fewer complications than percutaneous transthoracic needle biopsy; however, the current diagnostic yield is still necessitating further improvement. We aimed to evaluate the diagnostic yield of using virtual bronchoscopic navigation (VBN) and cone-beam CT (CBCT) for transbronchial biopsy and to investigate the factors that affected the diagnostic sensitivity. METHODS: We retrospectively investigated 255 patients who underwent VBN-CBCT-guided transbronchial biopsy at our two centers from May 2021 to April 2022. A total of 228 patients with final diagnoses were studied. Patient characteristics including lesion size, lesion location, presence of bronchus sign, lesion type and imaging tool used were collected and analyzed. Diagnostic yield was reported overall and in groups using different imaging tools. RESULTS: The median size of lesion was 21 mm (range of 15.5-29 mm) with 46.1% less than 2 cm in diameter. Bronchus sign was present in 87.7% of the patients. The overall diagnostic yield was 82.1%, and sensitivity for malignancy was 66.3%. Patients with lesion > 2 cm or with bronchus sign were shown to have a significantly higher diagnostic yield. Four patients had bleeding and no pneumothorax occurred. CONCLUSION: Guided bronchoscopy with VBN and CBCT was an effective diagnostic method and was associated with a high diagnostic yield in a safe manner. In addition, the multivariant analysis suggested that lesion size and presence of bronchus sign could be a predictive factor for successful bronchoscopic diagnosis.

An Innovative Method: Predicting the Visibility of Radial Endobronchial Ultrasound for Peripheral Pulmonary Nodules by Virtual Bronchoscopic Navigation.

Background: The diagnosis of peripheral pulmonary nodules (PPNs) still is the key and difficult point. Previous studies have demonstrated that the diagnostic yield of radial endobronchial ultrasound (rEBUS) visible nodules is significantly higher than that of invisible nodules. The traditional method of predicting the rEBUS-visibility of nodules is based on the CT-bronchus signs, but its effectiveness may be unsatisfactory. Objective: We innovate a valuable predictive model based on virtual bronchoscopic navigation to identify beforehand which PPNs are likely to be successfully visualized by rEBUS. The innovative predictor is the ratio of the size of lesions (S) to the shortest straight-line distance (D) from the terminal point of the virtual navigation path to the localization point of the nodule. Methods: This is a retrospective study. On the training dataset of 214 patients, a receiver operating characteristic curve was drawn to understand the utility of the predictive model and get the optimal cut-off points. Ninety-two cases were enrolled in the validation dataset to validate the external predictive accuracy of the predictor. Results: The optimal cut-off point of the curve was 1.84 with the Youden index of 0.65, at which point the area under the curve was 0.85 (95% CI: 0.76-0.95). The predictor has a good performance in the validation dataset with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 100%, 100%, 71%, and 87%, respectively. Conclusion: The S/D ratio is a valuable and innovative method to identify beforehand which PPNs are likely to be successfully visualized by rEBUS. If the S/D ratio of the nodule is greater than 1.84, it will be visualized by rEBUS.

The pattern of lymph node metastasis in peripheral pulmonary nodules patients and risk prediction models.

Background: For peripheral pulmonary nodules, the regularity of lymph node (LN) metastasis has not been studied. This study aimed to evaluate the metastasis pattern of intrapulmonary and relevant mediastinal lymph nodes in early-stage lung cancer, and further selected patients who were of low risk of LN metastasis as potential population to receive sub-lobectomy. Methods: This study prospectively included consecutive patients with peripheral clinical T1N0M0 disease who underwent complete resection with LN dissection or sampling from August 2014 to July 2015. The patients were followed up to 15, May 2021. Univariable or multivariable Logistic analysis was used to identify the risk factors. Models predicting LN metastasis risk were conducted. The area under the curve for the receiver operating characteristic curves was used to evaluate the diagnostic value. Disease-free survival and overall survival were compared between groups. Results: Finally, 201 patients were included in this study. For patients with negative tumor-bearing (TB) 13 and 14 station LNs, the positive rate of other lymph node stations was extremely low. Maximum CT value, pleural indentation and CEA level were risk factors for N1 station LNs metastasis. Besides, the factors above and lobulation sign were risk factors for skip metastasis beyond TB 13 and 14 station LNs. We constructed two scoring tables to predict N1 station metastasis and skip metastasis beyond TB 13 and 14 station. The AUC were 0·837 and 0·823, respectively. Based on the first table, 40·9% of patients suffered N1 station LNs metastasis and 27·3% had N2 disease in "high risk group" while the proportion was only 5·7% and 4·5% in "low risk group". For patients with negative TB13 and TB14 station LNs, based on the latter table, 11·1% of patients had N1 stations LNs metastasis and 16·7% had pN2 disease in "high risk group" while only 2·3% patients in "low risk group" suffered this kind of metastasis. Conclusion: For peripheral pulmonary nodules patients, stations 13 and 14 LNs may be the sentinel nodes. For patients with low risk of N1 metastasis and skip metastasis, sub-lobar resection might be sufficient for those who were of negative TB 13 and 14 station LNs.

Diagnostic yield of virtual bronchoscope navigation combined with radial endobronchial ultrasound guided transbronchial cryo-biopsy for peripheral pulmonary nodules: a prospective, randomized, controlled trial.

Background: Transbronchial lung biopsy (TBLB) was a useful method for the diagnosis of peripheral pulmonary nodules (PPNs), but the smaller tissue samples obtained often could not meet the subsequent molecular pathological diagnosis. The purposes of this study were to assess the diagnostic yield of virtual bronchoscope navigation (VBN) combined with radial endobronchial ultrasound (rEBUS) guided transbronchial cryo-biopsy (TBCB) and to compare it with TBLB. Methods: Patients with PPNs, who planned to undergo bronchoscopy and were admitted to Henan Provincial People's Hospital and Zhoukou Central Hospital from January 1, 2020 to December 31, 2020, were divided into the TBCB group (experimental group) and TBLB group (control group) using the block randomization method. TBCB and TBLB were performed with the guidance of VBN-rEBUS. The diagnostic yields, complications, specimen surface areas, and operation times were observed. The differences between the two groups were measured by the independent sample t-test or Chi-square test. Results: A total of 152 patients were enrolled, of whom 138 completed the study, and 102 received a definite diagnosis by bronchoscopy. The diagnostic yield showed no statistically significant difference between TBCB group and TBLB group (79.1% vs. 69.0%, P=0.124). For PPNs with the diameter <2 cm, TBCB group had a significantly higher diagnostic yield than TBLB group (76.5% vs. 50.0%, P=0.022); For PPNs with eccentric and adjacent radial ultrasonic images, TBCB group also had a significantly higher diagnostic yield than TBLB group (78.1% vs. 55.9%, P=0.023). The specimen surface area of TBCB group was larger than that of TBLB group (P=0.030). The incidence of moderate bleeding in TBCB group was higher than that in TBLB group (P=0.006), but no serious complications were observed in either group. Conclusions: Although the incidence rate of moderate bleeding was higher than that of TBLB, VBN-rEBUS guided TBCB is still a safe and effective diagnostic method for PPNs, and is superior to TBLB for PPNs with a diameter <2 cm or with an eccentric and adjacent radial ultrasonic image. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100054949.

Diagnostic value of LungPoint navigation combined with EBUS-GS & ROSE in peripheral pulmonary nodules.

Background & objectives: Recently, there has been a surge to develop new devices and techniques for the diagnosis of peripheral pulmonary lesions such as the combination of LungPoint navigation and endobronchial ultrasound with a guide sheath (EBUS-GS). The present study aimed to explore the diagnostic value of LungPoint navigation in combination with EBUS-GS and rapid on-site evaluation (ROSE) particularly for peripheral pulmonary nodules. Methods: Patients (n=108) with pulmonary nodules (10 mm ≤ nodal diameter ≤30 mm) presenting to Henan Provincial People's Hospital were detected using chest computed tomographic (CT) scanning and bronchoscopy. All patients were evaluated using LungPoint navigation, EBUS-GS and ROSE techniques to evaluate the positive rate of combined diagnosis using the three methods. Results: A total of 108 patients participated in this study and successfully underwent all the three procedures. Of these, 82 patients were accurately diagnosed, making the overall diagnostic rate of 75.9 per cent for combined LungPoint navigation, EBUS-GS, and ROSE analyses. Further subgroup analysis of the diagnostic rate of the three combined techniques were conducted based on the size of the nodules which showed a diagnostic rate of 65.3 per cent for 10 mm ≤ nodule diameter ≤20 mm and 85.7 per cent for 20 mm ≤ nodal diameter ≤30 mm. Of the 108 patients, 85 had solid nodules and 23 had ground-glass nodules; the positive rate of diagnosis of solid nodules was the highest. The patients ultimately were diagnosed with lung cancer with a positive rate of 83.5 per cent. The sensitivity, specificity and positive and negative predicted values for ROSE were 90.3, 78.3, 84.8 and 83.6 per cent, respectively. Interpretation & conclusions: The combined use of the three techniques can effectively shorten the duration of the total diagnosis period and improve the safety of diagnosis without affecting the detection rate.

Peripheral pulmonary nodule diagnosed as mycobacterium chelonae using electromagnetic navigation bronchoscopy combined with next generation sequencing: a case report.

We report the case of a 29-year-old female with a 1.1 cm × 1.1 cm solitary nodule adjacent to the pleura in the upper lobe of the right lung that was diagnosed as Mycobacterium chelonae using electromagnetic navigation bronchoscopy combined with next generation sequencing. This diagnostics technology shows great promise in identifying peripheral pulmonary nodules, especially infectious lesions.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules.

BACKGROUND: Small peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used to locate pulmonary nodules, but this method has many limitations. Thus, we aimed to evaluate the accuracy and feasibility of electromagnetic navigational bronchoscopy (ENB) with pleural dye to locate small peripheral pulmonary nodules before video-associated thoracic surgery (VATS). METHODS: The ENB localisation procedure was performed under general anaesthesia in an operating room. Once the locatable guide wire, covered with a sheath, reached the ideal location, it was withdrawn and 0.2-1.0 mL of methylene blue/indocyanine green was injected through the guide sheath. Thereafter, 20-60 mL of air was instilled to disperse the dye to the pleura near the nodules. VATS was then performed immediately. RESULTS: Study subjects included 25 patients with 28 nodules. The mean largest diameter of the pulmonary nodules was 11.8 mm (range, 6.0-24.0 mm), and the mean distance from the nearest pleural surface was 13.4 mm (range, 2.5-34.9 mm). After the ENB-guided localisation procedure was completed, the dye was visualised in 23 nodules (82.1%) using VATS. The average duration of the ENB-guided pleural dye marking procedure was 12.6 min (range, 4-30 min). The resection margins were negative in all malignant nodules. Complications unrelated to the ENB-guided localisation procedure occurred in two patients, including one case of haemorrhage and one case of slow intraoperative heart rate. CONCLUSION: ENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection. TRIAL REGISTRATION NUMBER: ChiCTR1900021963.

State-of-the-Art Modalities for Peripheral Lung Nodule Biopsy.

Lung nodules are being increasingly detected, particularly with lung cancer screening with low-dose computed tomography. Although the vast majority of lung nodules are benign, many often require tissue diagnosis. Several modalities to obtain diagnostic tissue from peripheral lung nodules are available. Bronchoscopic modalities such as radial ultrasound and electromagnetic navigational bronchoscopy are becoming increasingly used because of their superior safety profile and improving diagnostic yield. Although these modalities continue to become more advanced, newer and complementary technologies appear promising.

Diagnosti value of joint evaluation of radial ultrasound, virtual navigation and ultrathin bronchoscope in peripheral pulmonary nodules / 重庆医学

Objective To explore the diagnostic value of radial ultrasound (EBUS) combined with virtual navigation (VBN) in peripheral pulmonary nodules.Methods Two hundreds and forty cases of peripheral pulmonary nodules(0.8 cm≤diameter≤3 cm) in the respiratory department of our hospital from July 2014 to July 2015 were included and according to the different guide de vices,which were divided into the radial ultrasound combined with virtual navigation group (EBUS+ VBN group),radial ultrasound group (EBUS group),virtual navigation group (VBN group) and control group.The diagnostic rates were compared among the four groups and among different sizes of lesion.The time of lesion location and operating time were also compared between the EBUS+ VBN group and EBUS group.Results Among 240 cases,the diagnostic rate in the EBUS+VBN group was highest(81.67％),and the diagnostic rates had statistically significant difference among the four groups (x2=19.344,P=0.00);the diagnostic rates of lesions less than 2 cm in diameter were lower than that of lesions ＞2 cm in the EBUS+-VBN group and EBUS group,but without statistically significant difference (x2 =2.04,3.40,P =0.15,0.07);the locating lesions time and operating times in the EBUS+ VBN group were shorter than those in the EBUS group,but the difference between them was not statistically significant (P=0.03,0.04).Conclusion EBUS combined with VBN could improve the diagnostic rate of peripheral pulmonary nodules and shorten the time of lesion location and operating time.

Electromagnetic Navigational Bronchoscopy for Peripheral Pulmonary Nodules.

Electromagnetic navigational bronchoscopy is a useful addition to the array of modalities available to sample peripheral lung lesions. Its utility in diagnosing peripheral lesions has been steadily increasing since the Food and Drug Administration first approved it in 2004. The improvement can be attributed to continuous refinement in technology, increasing training and experience with the procedure, perhaps widespread availability of rapid onsite cytologic evaluation, and better patient selection. It may also be attributable to improvements of the technology and more available tools to perform biopsy of the peripheral lung.

Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia.

BACKGROUND: American College of Chest Physicians (CHEST) clinical practice guidelines on the evaluation of pulmonary nodules may have low adoption among clinicians in Asian countries. Unique patient characteristics of Asian patients affect the diagnostic evaluation of pulmonary nodules. The objective of these clinical practice guidelines was to adapt those of CHEST to provide consensus-based recommendations relevant to practitioners in Asia. METHODS: A modified ADAPTE process was used by a multidisciplinary group of pulmonologists and thoracic surgeons in Asia. An initial panel meeting analyzed all CHEST recommendations to achieve consensus on recommendations and identify areas that required further investigation before consensus could be achieved. Revised recommendations were circulated to panel members for iterative review and redrafting to develop the final guidelines. RESULTS: Evaluation of pulmonary nodules in Asia broadly follows those of the CHEST guidelines with important caveats. Practitioners should be aware of the risk of lung cancer caused by high levels of indoor and outdoor air pollution, as well as the high incidence of adenocarcinoma in female nonsmokers. Furthermore, the high prevalence of granulomatous disease and other infectious causes of pulmonary nodules need to be considered. Therefore, diagnostic risk calculators developed in non-Asian patients may not be applicable. Overall, longer surveillance of nodules than those recommended by CHEST should be considered. CONCLUSIONS: TB in Asia favors lesser reliance on PET scanning and greater use of nonsurgical biopsy over surgical diagnosis or surveillance. Practitioners in Asia are encouraged to use these adapted consensus guidelines to facilitate consistent evaluation of pulmonary nodules.