PURPOSE: Pulmonary nodules are frequently encountered in clinical practice. Sensitivity of traditional bronchoscopy and fluoroscopic transbronchial biopsy is only 34% for nodules <2 cm and 63% for lesions >2 cm in size in malignant disease (1), and is likely less for non-malignant etiologies. Navigational bronchoscopy technologies, such as radial ultrasound (RU), have increased yields for diagnosing peripheral malignancies (2). Presence of a CT bronchus sign has also been reported to increase yields to 79% with electromagnetic navigation bronchoscopy (EMN) (3). We examine the impact of the bronchus sign with RU bronchoscopy for diagnosing peripheral lung nodules.
METHODS: Retrospective review of 40 consecutive patients with RU-guided transbronchial biopsy of lung nodules ≤3 cm was performed. The RU probe was passed through a guide-sheath catheter which served as an extended working channel for biopsy instruments after the probe was removed. Fluoroscopy was used to ensure stable guide-sheath positioning between multiple biopsies. Malignancy was determined by bronchoscopic or subsequent diagnostic procedure. Lesions were considered benign if an alternative non-malignant pathology was established with bronchoscopic RU-guided biopsy or on subsequent surgical resection or ≥6 month radiographic stability or regression.
RESULTS: Mean patient age was 64.8±11.4 (SD) years with an average of 27.9±31.5 (SD) pack years of tobacco use. Mean nodule size was 2.04±0.60 (SD) cm. 42.5% (17/40) of the nodules were malignant and 42.5% (17/40) were benign. Follow-up data was not available for 15% (7/40) of cases. Sensitivity of RU navigational bronchoscopy was 65.0% (26/40) with a sensitivity of 70.6% (12/17) in malignant cases. A CT “bronchus sign” was present in 70.6% (12/17) of malignant cases, and sensitivity of RU-guided bronchoscopy with a “bronchus sign” was 83.3% (10/12) compared to 40.0% (2/5) without.
CONCLUSIONS: For malignant pulmonary nodules, RU-guided transbronchial biopsy can provide a diagnostic yield similar to EMN bronchoscopy.
CLINICAL IMPLICATIONS: RU provides real-time radiographic confirmation of accurate localization of peripheral lung lesions without pre-procedure virtual planning time or expense of the disposable steerable guide required in EMN bronchoscopy.
DISCLOSURE: The following authors have nothing to disclose: David Hsia, Kurt Jensen, Ali Musani
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