Evaluation of Electromagnetic Navigational Bronchoscopy Using Tomosynthesis-Assisted Visualization, Intraprocedural Positional Correction and Continuous Guidance for Evaluation of Peripheral Pulmonary Nodules

Abstract

Background: Electromagnetic navigational bronchoscopy (ENB) has been shown to have variable diagnostic accuracy for the assessment of peripheral pulmonary nodules. This may be because of discrepancies between the preplanned computed tomography of chest target lesion location versus actual target location (computed tomography-to-body divergence), and the lack of a continuous navigational image. The ILLUMISITE (Medtronic, Minneapolis, MN) is a newly developed ENB platform that utilizes tomosynthesis, an imaging technology that can visualize the target location using fluoroscopy (F-ENB). This new system also allows for intraprocedural positional correction and continuous navigation guidance during sampling to overcome these limitations and improve diagnostic yield. We report our first experience in a single center, single proceduralist using this new technology. Methods: We conducted a retrospective, single center, single operator study reviewing 72 consecutive patients (78 nodules) over a 3-month period. We investigated the overall diagnostic yield and diagnostic yield by nodule location, size, and sedation type using this new F-ENB system. Results: The overall diagnostic yield was 87% and pnemothoraces occurred in 2/78 procedures. We did not find any statistically significant difference when comparing pulmonary nodule location, size or sedation method utilized ( P =0.231, 0.338, and 0.112, respectively). Sixty-nine percent of the pulmonary nodules biopsied were 2 to 3 cm in size. The average distance corrected after tomosynthesis visualization was 15.4 mm (0.4 to 29.8 mm). Conclusion: We report our initial experience with the ILLUMISITE system using fluoroscopic tomosynthesis-assisted visualization with continuous navigational guidance at our institution. This new technology allows the operator to correct for better target lesion alignment and real time positional correction and may improve diagnostic yields with minimal complications for evaluation of peripheral pulmonary nodules.

Electromagnetic navigation bronchoscopy transbronchial lung nodule ablation with IllumisiteTM platform corrects CT-to-body divergence with tomosynthesis and improves ablation workflow: a case report

“…Throughout procedure, it provides real time confirmation that the catheter is aligned to the nodule, and this alignment can be maintained even after the LG is removed, owing to the presence of sensor coils embedded in the tip of EWC. This continuous positional data allows for multidirectional sampling and more thorough biopsy, as have been demonstrated in biopsy series using this platform ( 7 , 8 ).…”

Treatment strategies for malignant pulmonary nodule: beyond lobectomy. Point-counterpoint

“…Inaccurate navigation from CT-to-body divergence can lead to excessive CBCT requirement and instrument re-navigation [112][113]. To reduce the CT-to-body divergence, innovative navigation systems such as Illumisite and Galaxy robotic bronchoscopy platforms utilize integrated fluoroscopic technology and tomosynthesis-based navigation correction to provide continuous positional information of the lesion position and real-time catheter position confirmation, thus reduce reliance on CBCT or need for instrumental re-positioning [114][115][116]. A randomized trial -the RELIANT trial comparing the diagnostic yield of the Ion ENB platform and the Illumisite RAB platform is currently in progress [117], and these technologies are highly anticipated to enhance the applicability in BMWA [118].…”

Evaluation of Novel Technology Targeting the Lung Periphery “Just Because We Can…”

“…In this issue of JOBIP, Dunn et al3 describe their early experience with a modified ENB technique for sampling PPNs: ENB with tomosynthesis-assisted visualization, intraprocedural positional correction and continuous guidance. As described in detail in the article, this technology allows for correction of computed tomography-to-body divergence and uses continuous navigational guidance during bronchoscopic sampling, addressing two of the main weaknesses of conventional ENB 4.…”

“…We wondered whether in our quaternary-care, academic clinical practice we could perform such a high number of procedures targeting the lung periphery, as linear EBUS remains a first-line technique for diagnosis and staging of patients with suspected lung cancer 6. We found the answer in Table 1 of the manuscript3: 65% of patients in this series had a suspected clinical stage >I, suggesting that many could have been diagnosed with linear EBUS sampling of hilar and/or mediastinal nodes. Guidelines recommend an invasive approach that achieves concomitant diagnosis and staging, whenever safely feasible 8–10.…”