Electromagnetic Navigation Bronchoscopy in the Diagnosis of Peripheral Lung Lesions

Abstract

Diagnosis of peripherally located lung masses is of low yield with flexible bronchoscopy and carries a high risk of pneumothorax with transthoracic fine needle aspiration. Electromagnetic navigation bronchoscopy has been used in these situations with reported high diagnostic yield and low risk of complications. We carried out a review of literature to assess the diagnostic yield and complication rate of electromagnetic navigation bronchoscopy compared with the traditionally used modalities for the diagnosis of peripheral lung lesions. (Clin Pulm Med 2011;18:42-45) T he increasing use of computed tomography (CT) scan has resulted in the finding of more than 150,000 solitary pulmonary nodules in the United States per year. 1 These are often followed by yearly CT scans, exposing the patient to the risks associated with radiation. 2 Moreover, the prognosis of lung cancer depends on the timely diagnosis and the stage of the disease. Bronchoscopy is the diagnostic tool of choice for central lesions, that is, masses located in the more proximal airways. The bronchoscopic yield for neoplasms located in the outer third of the lung is less than 30%. 3-5 Peripherally located nodules that are less than 2 cm in diameter have an even lower yield using bronchoscopy (14%). 3 For peripheral nodules, the modalities used for diagnosis include surgical resection, with higher morbidity and mortality (0.5%-5.3%), 6 and transthoracic fine needle aspiration (TTFNA). The diagnostic yield of TTFNA is 64% to 97% 7-9 with a diagnostic accuracy of 94% 7 but the risk of pneumothorax ranges between 23% and 44%. 3,10-12 The risk of pneumothorax increases if there is a coexistent emphysema and increases 4-fold if the lesion is more than 2 cm away from the pleura. 13 Electromagnetic navigation bronchoscopy (ENB) has been introduced as a diagnostic tool for bronchoscopic biopsy of peripheral lung nodules, with a potential to decrease the risk of pneumothorax yet maintain the diagnostic yield observed with surgical resection or TTFNA. MYTHENB has a lower risk of complications with diagnostic yields comparable to TTFNA. DATAIn 2005, Hautmann et al 14 published data on 16 patients who were prospectively evaluated using ENB and fluoroscopy. Five patients had solitary pulmonary nodules, 8 had lung infiltrates, and 3 had lung masses. The average nodule size was 22 ± 6 mm. Three of the 5 solitary pulmonary nodules and all 3 lung masses biopsied were positive for malignancy, whereas 5 of the 8 infiltrates biopsied gave positive results consistent with granulomas, invasive aspergillosis, radiation pneumonitis, interstitial lung disease, and bronchioalveolar cell carcinoma. The procedure time compared with regular bronchoscopy was increased by 3.9 ± 1.3 minutes with the use of navigation bronchoscopy. There were no complications. The authors concluded that electromagnetic navigation was safe and useful in the diagnosis of small or fluoroscopically invisible lung lesions (Table 1, evidence grade C).Becker et al 16 published prospective data on 29 bronchos...

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