PURPOSE: Patients with lung nodules often require tissue analysis to guide further management. New techniques, such as peripheral endobronchial ultrasonography (pEBUS) and Electromagnetic Navigation Bronchoscopy (ENB), have improved the diagnostic yield of bronchoscopy in this setting. In an attempt to reduce the significant cost of this combined approach, the ENB technique could be used as a rescue if pEBUS is not able to initially identify the lesion. This study aims to determine the diagnostic yield and factors that help necessitate the use of this sequential approach in patients with lung nodule(s).
METHODS: Multi-centre prospective cohort study of patients with one or more non-pleural based/non-endobronchial lung nodules (1-6cm). Virtual bronchoscopic planning was performed with ENB software. A pEBUS probe and guide-sheath were used to locate the nodule. If unsuccessful in locating the lesion, ENB was then used in combination with pEBUS during the same procedure. Once located, lesion samples were taken through the guide sheath. Chest radiographs were performed post procedure.
RESULTS: 60 patients were enrolled into the study(29m/32f). The average lesion size was 27mm with a mean distance of 20mm from the costal pleura. The malignancy rate was 86%. The lesion was found with pEBUS alone in 45 cases (75%) and with the addition of ENB in 11/15 (73%) cases resulting in overall lesion identification in 56/60 cases (93%). Factors predicting the need for ENB included lesion size (21.5 vs 29.7mm, p< 0.05) and lack of an air bronchus sign on computed tomography. When pEBUS was used alone, a diagnosis was achieved in 26/45 cases and ENB added 4 additional diagnoses in the remaining 15 cases. The adjusted yields for pEBUS alone and pEBUS with ENB were 43% and 50%, respectively. Improved tissue yield was obtained when pEBUS was within vs adjacent to the lesion (64% vs 39%, p<0.01) The overall pneumothorax rate was 8.3% (3.3% requiring chest tube).
CONCLUSIONS: A high lesion identification rate can be achieved with pEBUS alone. ENB allows the identification of a substantial number of additional lesions not initially located with pEBUS alone. A smaller lesion diameter and lack of a CT air bronchus sign may predict cases where ENB will be required. Despite a high lesion identification rate, diagnostic yield was low.
CLINICAL IMPLICATIONS: ENB is a useful tool when pEBUS alone is unable to locate peripheral lung lesions. Improved sampling methods for peripheral nodules are required to further improve diagnostic yield.
DISCLOSURE: The following authors have nothing to disclose: Alex Chee, David Stather, Paul MacEachern, Simon Martel, Antoine Delage, Matheiu Simon, Elaine Dumoulin, Alain Tremblay
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