Improved diagnostic yield for lung nodules with digital tomosynthesis‐corrected navigational bronchoscopy: Initial experience with a novel adjunct

Abstract

Background and objective The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is inferior to that of computed tomography (CT)‐guided needle biopsy for pulmonary nodules. One explanation for this is divergence between the nodule location on the pre‐procedure CT scan and its actual location during the procedure. Fluoroscopic ENB (F‐ENB) consists of digital tomosynthesis using a conventional C‐arm to re‐register the target lesion based on near real‐time imaging. We performed a retrospective review of ENB cases at our institution before and after introduction of F‐ENB to assess diagnostic yield. Methods All consecutive ENB procedures performed at our institution from 25 December 2017 to 25 August 2018 were reviewed. F‐ENB was introduced on 25 April 2018. Two cohorts were analysed: standard ENB (S‐ENB) from 25 December 2017 to 24 April 2018 and F‐ENB from 25 April 2018 to 25 August 2018. All procedural, demographic and diagnostic data were collected. Descriptive statistics, chi‐square, Wilcoxon test and Student's t‐test were used where appropriate. A multivariable regression analysis was performed to assess factors associated with diagnostic yield. Results A total of 101 and 67 nodules were biopsied in the S‐ENB and F‐ENB groups, respectively. Diagnostic yield was 54% in S‐ENB cohort and 79% in the F‐ENB group (P = 0.0019). Factors independently associated with a positive diagnosis were F‐ENB and a positive radial ultrasound view (odds ratio (OR): 3.57, 95% CI: 1.56–8.18 and OR: 3.74, 95% CI: 1.37–11.05, respectively). Complications were minimal (pneumothorax: 1.5%). Conclusion The use of F‐ENB may increase the diagnostic yield of ENB and has a low complication rate.

Cone-Beam Computed Tomography-Guided Electromagnetic Navigation for Peripheral Lung Nodules

“…ENB, although real time, is a virtual confirmation of the nodule location which completely depends on the location of the nodule at the time of the CT chest utilized for ENB preplanning. It has been well documented that a lung nodule can diverge from its location due to factors such as lung volumes; full inhalation versus tidal breathing; patient positioning, for example, pillow under head or extended arms; and diaphragm position under positive pressure ventilation and paralytics [17]. ENB inherently will navigate to the deviated location for the same reason.…”

High Accuracy of Digital Tomosynthesis-Guided Bronchoscopic Biopsy Confirmed by Intraprocedural Computed Tomography

“…First, standard ENB was performed as previously described [12]. Following the initial navigation, a REBUS probe was inserted through the extended working channel (EWC).…”

“…Following the initial navigation, a REBUS probe was inserted through the extended working channel (EWC). The locatable guide was reinserted and a 50° sweep was performed with the C-arm [12]. Using digital tomosynthesis, high-resolution images of the nodule are generated, and the true nodule location is marked.…”

“…This information updates the location of the target as projected on the navigation console, allowing the bronchoscopist to adjust and direct the catheter more precisely toward the nodule’s current location. Aboudara et al [12] recently demonstrated improved diagnostic yield of F-ENB compared to traditional ENB with no increase in complications. This technique may be particularly useful with smaller nodules and without a bronchus sign.…”

Improving electromagnetic navigation: One nodule at a time

“…In an effort to improve diagnostic yield, Aboudara et al . in a recent publication in Respirology integrated digital tomosynthesis into their navigation system, using their existing C‐arm fluoroscope to re‐register the intended parenchymal target lesion in real time during ENB. The integration software is proprietary, and therefore offered on only one commercially available navigational platform.…”