Transbronchial Biopsy Using an Ultrathin Bronchoscope Guided by Cone-Beam Computed Tomography and Virtual Bronchoscopic Navigation in the Diagnosis of Pulmonary Nodules

Abstract

<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.

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

“…Also, the mean size of pulmonary nodules was 21 mm, which is larger than our median nodule size of 16 mm. Ali et al [11] reported a prospective case series of 40 patients with a combination of ultrathin bronchoscope, ENB, and CBCT achieving a diagnostic yield of 90%, which is higher than our yield. However, the likely explanation for such a high yield is inclusion of nodules with bronchus sign only and inclusion of nonspecific inflammation in diagnostic yield calculation.…”

“…This is in contrast to the transbronchial approach, in which the risk of pneumothorax is only around 0.02–4.9% [7-10]. Furthermore, CT-guided TTNA might be associated with a higher incidence of local recurrence with pleural dissemination than transbronchial or open lung biopsy [11].…”

“…The diagnostic yield of transbronchial biopsy guided by fluoroscopy is widely variable, ranging from 18 to 80%, and is strongly dependent on the lesion size [12, 13]. In order to increase the diagnostic yield of the transbronchial approach, techniques and devices such as the ultrathin bronchoscope, radial endobronchial ultrasonography with guided sheath, electromagnetic navigation bronchoscopy (ENB), and cone-beam computed tomography (CBCT) are becoming widely utilized [11].…”

Cone‐beam computed tomography versus computed tomography‐guided ultrathin bronchoscopic diagnosis for peripheral pulmonary lesions: A propensity score‐matched analysis

“…CBCT‐guided TBB using UTB under VBN was performed as previously described 19 . CT‐guided TBB was performed using almost the same procedure, but the equipment used varied depending on the time of examination.…”

“…In percutaneous transthoracic biopsy, it has been reported that some benefits of the CBCT‐guided biopsy, when compared to the CT‐guided biopsy, include accessibility by means of a flexible approach with an open gantry 15–18 . Taking advantage of this characteristic, we introduced a CBCT‐guided TBB using UTB under VBN as an alternative to a CT‐guided TBB, which has a previously reported diagnostic yield of 90% 19 . However, the advantage of CBCT‐guided TBB using UTB under VBN over CT‐guided TBB using UTB under VBN is still unknown.…”