Diagnostic Yield of Digital Tomosynthesis-assisted Navigational Bronchoscopy for Indeterminate Lung Nodules

Abstract

Background: Navigational bronchoscopy is commonly used to sample lung nodules, with a better safety profile but lower diagnostic yield than computerized tomography-guided transthoracic needle biopsy. The addition of digital tomosynthesis to electromagnetic navigation, using intraprocedural images obtained from a C-arm fluoroscope to identify target lesion location and update navigational guidance, may improve diagnostic yield.Methods: Consecutive bronchoscopies using tomosynthesis-assisted fluoroscopic electromagnetic navigational bronchoscopy (F-ENB) at a single institution over a 1-year period were included. The primary outcome was diagnostic yield. A bronchoscopy was defined as diagnostic if pathologic examination revealed malignancy or specific histological findings indicative of lesional sampling with confirmatory 6-month follow-up for benign lesions.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

“…A diagnostic yield of 77% was observed, with a pneumothorax rate of only 2.5% (8/324) [10]. While future randomized studies are necessary to confirm these results, this data suggests that a ventilation protocol optimized for advanced guided bronchoscopy not only reduces atelectasis, but may also increase in diagnostic yield.…”

“…However, with one exception [ 28 ], the studies described above used navigation bronchoscopy systems without intraprocedural advanced imaging. Newer systems such as tomosynthesis-based fluoroscopic navigation [ 10 ] and CT augmented fluoroscopy [ 28 ] require a breath hold to minimize lung movement during intraprocedural imaging and location adjustments. Furthermore, CT-to-body divergence and atelectasis are likely strong contributors to the sub-optimal diagnostic yield seen with earlier generations of navigation bronchoscopy technology in large multicenter studies [ 30 ].…”

“…A study of tomosynthesis-based fluoroscopic navigation used a similar ventilation protocol, with intubation under TIVA, neuromuscular blockade, a recruitment maneuver after intubation, minimized oxygen, and 15 cm H 2 O applied throughout the procedure. A diagnostic yield of 77% was observed, with a pneumothorax rate of only 2.5% (8/324) [ 10 ]. While future randomized studies are necessary to confirm these results, this data suggests that a ventilation protocol optimized for advanced guided bronchoscopy not only reduces atelectasis, but may also increase in diagnostic yield.…”

“…This effect refers to a mismatch between the preprocedure CT-based virtual map used to plan the navigation route to the lung lesion and the actual dynamic lung anatomy during bronchoscopy. This divergence can be caused by a number of factors [8] and has been addressed, in part, by advanced bronchoscopy systems that provide real-time visualization and/ or positional correction during the bronchoscopy procedure [9][10][11][12][13][14][15][16][17][18]. However, anesthesia-induced atelectasis remains a challenge that can obscure lesion visibility and cause inaccurate localization, even with intraprocedural positional correction.…”

Assessing Performance of Bronchoscopic Diagnostic Techniques

“…5,6 New technologies to further improve bronchoscopic diagnosis of PPL are being investigated, such as robotic bronchoscopy, cone-beam CT scanning, and augmented fluoroscopy. [7][8][9][10][11][12] In this issue of CHEST, Herth et al 13 report the results of a retrospective observational cohort study of transbronchial lung cryobiopsy (TLCB) for PPL. The study enrolled all patients who had TLCB for PPL $2 cm in size suspicious for lung cancer.…”