<b><i>Background:</i></b> Transbronchial biopsy is a safe diagnostic approach for patients with peripheral pulmonary lesions; however, the diagnostic yield is low. <b><i>Objectives:</i></b> This study was conducted to evaluate the feasibility and diagnostic yield of transbronchial biopsy using the combination of an ultrathin bronchoscope, virtual bronchoscopic navigation (VBN), and cone-beam computed tomography (CBCT). <b><i>Methods:</i></b> Patients with peripheral pulmonary lesions, no >30 mm, with the responsible bronchus, were prospectively included. An ultrathin bronchoscope and biopsy forceps were advanced to the target bronchus under VBN, 2D-fluoroscopy, and CBCT. We categorized the CBCT findings before biopsy into 3 types according to positions of the target lesion and forceps (CBCT target-forceps sign). In type A, the forceps reached the inside of the target lesion. In type C, the forceps could not reach the lesion. When the CBCT findings could not be categorized into either type A or C, the sign was categorized as type B. <b><i>Results:</i></b> Although the target lesions were invisible by conventional C-arm fluoroscopy in 29 patients, CBCT visualized all 40 lesions. The overall diagnostic yield was 90.0%, and diagnostic yields for malignant and benign lesions were 92.0 and 86.7%, respectively. Diagnostic yields for CBCT target-forceps sign types A, B, and C were 100, 75.0, and 0%, respectively. Four undiagnosed patients proceeded to other diagnostic procedures based on the CBCT target-forceps sign (type B: <i>n</i> = 2, type C: <i>n</i> = 2) and were correctly diagnosed without delay. <b><i>Conclusions:</i></b> Transbronchial biopsy using an ultrathin bronchoscope guided by CBCT and VBN showed a very high yield in the diagnosis of pulmonary nodules.
887 patients screened, 44 patients were identified fitting inclusion criteria with sufficient additional tissue for testing. The mean age and smoking history were 68 ± 10 years and 45 pack-year history, respectively. The patients were majority male (61%) and Caucasian (75%). Fifty-two percent of patients were stage 1 at the time of diagnosis, 34% were stage 2, and 14% were stage 3a. Three patients (6.8%) were found to have pan-cytokeratin positive MMs. All 3 MMs detected were at N2 LN stations. The presence of MMs was associated with significantly decreased progression-free (median 210 vs. 1293 days, p¼0.0099) and overall survival (median 238 vs. 1120 days, p¼0.0357). Conclusion: LN micro-metastases can be detected during EBUS-TBNA staging examinations and are associated with poor clinical outcomes. If prospectively confirmed in a larger study, these results have significant implications for EBUS-TBNA specimen analyses and the current NSCLC staging paradigm.
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