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Original Research: Pulmonary Procedures |

High Yield of Bronchoscopic Transparenchymal Nodule Access Real-Time Image-Guided Sampling in a Novel Model of Small Pulmonary Nodules in CaninesTransparenchymal Nodule Access FREE TO VIEW

Daniel H. Sterman, MD, FCCP; Thomas Keast, BSME; Lav Rai, PhD; Jason Gibbs, PhD; Henky Wibowo, MSECE; Jeff Draper, MS; Felix J. Herth, MD, FCCP; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the University of Pennsylvania Medical Center (Dr Sterman), Philadelphia, PA; Broncus Medical (Messrs Keast, Wibowo, and Draper and Drs Rai and Gibbs), Mountain View, CA; the Department of Pneumology and Critical Care Medicine (Dr Herth), Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, Germany; and the Medical University of South Carolina (Dr Silvestri), Charleston, SC.

CORRESPONDENCE TO: Daniel H. Sterman, MD, FCCP, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine of the University of Pennsylvania, 833 Gates Bldg, 3400 Spruce St, Philadelphia, PA; e-mail: daniel.sterman@uphs.upenn.edu


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):700-707. doi:10.1378/chest.14-0724
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BACKGROUND:  Bronchoscopic transparenchymal nodule access (BTPNA) is a novel approach to accessing pulmonary nodules. This real-time, image-guided approach was evaluated for safety, accuracy, and yield in the healthy canine model.

METHODS:  A novel, inorganic model of subcentimeter pulmonary nodules was developed, consisting of 0.25-cc aliquots of calcium hydroxylapatite (Radiesse) implanted via transbronchial access in airways seven generations beyond the main bronchi to represent targets for evaluation of accuracy and yield. Thoracic CT scans were acquired for each subject, and from these CT scans LungPoint Virtual Bronchoscopic Navigation software provided guidance to the region of interest. Novel transparenchymal nodule access software algorithms automatically generated point-of-entry recommendations, registered CT images, and real-time fluoroscopic images and overlaid guidance onto live bronchoscopic and fluoroscopic video to achieve a vessel-free, straight-line path from a central airway through parenchymal tissue for access to peripheral lesions.

RESULTS:  In a nine-canine cohort, the BTPNA procedure was performed to sample 31 implanted Radiesse targets, implanted to simulate pulmonary nodules, via biopsy forceps through a specially designed sheath. The mean length of the 31 tunnels was 35 mm (20.5-50.3-mm range). Mean tunnel creation time was 16:52 min, and diagnostic yield was 90.3% (28 of 31). No significant adverse events were noted in the status of any of the canine subjects post BTPNA, with no pneumothoraces and minimal bleeding (all bleeding events < 2 mL in volume).

CONCLUSIONS:  These canine studies demonstrate that BTPNA has the potential to achieve the high yield of transthoracic needle aspiration with the low complication profile associated with traditional bronchoscopy. These results merit further study in humans.

Figures in this Article

The diagnosis of peripheral lung nodules is a common clinical issue encountered by primary care physicians, pulmonologists, and thoracic surgeons. The decision process each physician must embark upon for these peripheral lesions includes consideration for further radiographic observation, metabolic imaging with PET scans, biopsy, or proceeding directly to surgical resection. If the decision is to perform biopsy of a peripheral lung nodule, the physician also has to choose the diagnostic modality: bronchoscopy, transthoracic needle aspiration (TTNA) under fluoroscopic or CT scan guidance, or videothoracoscopic biopsy.14

TTNA is a diagnostic modality that is frequently used when accessing peripheral pulmonary lesions. Although TTNA generally provides a high diagnostic yield (upward of 90% in some series),5,6 it also results in a clinically significant rate of pneumothorax as well as the risk of other complications, including localized hemorrhage/hemoptysis and air embolism.6,7 Videothoracoscopy provides the highest diagnostic yield, assuming a peripheral lung nodule can be identified and/or palpated by the surgeon to allow for removal of the lesion. This may be a challenging proposition for many of the ground-glass nodules that may be identified on screening chest CT scans. Videothoracoscopy nodule resection is an invasive procedure that requires two to three incisions, general anesthesia, and inpatient hospitalization and is associated with postprocedural pain and significant cost.8,9 In addition, as illustrated by the findings of the National Lung Screening Trial, the preponderance of peripheral nodules identified on screening or surveillance chest CT scans are benign in nature—particularly if < 2 cm in diameter10,11—and, therefore, do not warrant such an aggressive approach as surgical removal, even with minimally invasive techniques.

Flexible bronchoscopy is a widely used and safe procedure that is performed by the majority of pulmonologists in the United States. Bronchoscopy can be used to diagnose peripheral lung nodules, although the yield of standard bronchoscopic diagnostic techniques—including washings, brushings, and forceps biopsies—is unacceptably low for small nodules < 2 cm in diameter.12 Transbronchial needle aspiration is a technique that has wide applications in the diagnosis of hilar and mediastinal adenopathy and peribronchial masses but also has been implemented for access to peripheral nodules, often with fluoroscopic guidance.6 Standard flexible bronchoscopy is associated with a significantly reduced diagnostic yield for peripheral lung lesions compared with TTNA but carries a superior safety profile.2,6 In the past decade, a variety of navigational bronchoscopic approaches have been introduced into clinical practice, which have improved the yield of diagnostic bronchoscopy for peripheral lung nodules, including: virtual bronchoscopic navigation, radial probe ultrasound (with/without guide sheath), and electromagnetic navigation.3,13 However, none of the navigational guidance technologies to facilitate bronchoscopic sampling of peripheral lung nodules approaches the diagnostic yield of TTNA, in part because each of these approaches is limited by the requirement of passage through the small airways at the periphery of the lung. These navigational techniques have difficulty in accessing peripheral lung nodules for which there is not a “bronchus sign” on CT scan, and the yield for any of these technologies for nodules < 1 cm in diameter is unacceptably low.14 There is, therefore, a significant clinical need for improvement in mechanisms of bronchoscopic access to small pulmonary nodules.

LungPoint VBN (Broncus) is a virtual bronchoscopic navigation system that provides guidance to specific targets through multiple airway generations by the use of image processing without the use of sensors to a user-defined region of interest.15 Transparenchymal nodule access (TPNA) software algorithms automatically generate point-of-entry (POE) recommendations, register CT and real-time fluoroscopic images, and overlay guidance onto live bronchoscopic and fluoroscopic video for access to peripheral lesions. Developed in conjunction with this software is an array of devices to enable repeated access to lesions with standard 2.0-mm working channel tools.

We have previously described both the method and safety of the bronchoscopic TPNA (BTPNA) procedure in a canine model, describing both a low risk of serious bleeding or pneumothorax and the ability to extend the sampling devices in close proximity to previously implanted target fiducial markers.16 Unfortunately, there are no large animal models of lung cancer that can be used for in vivo studies of novel navigational technologies. There have been attempts at creating simulated pulmonary nodules for study in animal models, but none have allowed for sampling with standard bronchoscopy technologies that would allow for pathologic analysis of biopsy specimens to confirm successful access of the nodule.17,18 We undertook this study to assess the ability of BTPNA to safely provide a pathologically confirmed biopsy in a novel canine model of simulated pulmonary nodules < 1 cm in diameter.

This study was performed in canines (approximate weight, 20 kg) using best practices and approved by the Institutional Animal Care and Use Committee at the University of Utah. All dogs were killed afterward. The animal studies were conducted between June and November 2011.

Development of Targets for Sampling

To represent malignant lesions visible on CT scan but invisible on fluoroscopy, 0.25-cc aliquots of calcium hydroxylapatite filler (Radiesse Volumizing Filler; Merz Aesthetics, Inc) were injected transbronchially via the 18-gauge FleXNeedle (Model 10005; Broncus) into the lung parenchyma of canines. Radiesse is a US Food and Drug Administration-approved injectable implant composed of synthetically produced smooth calcium hydroxylapatite (CaHA) microspheres (diameter, 25-45 μm) suspended in a sodium carboxymethylcellulose gel carrier. Radiesse volumizing filler is approximately 30% CaHA and 70% gel carrier by volume. It is primarily used medically in the fields of dermatology and plastic surgery for subcutaneous/intradermal injections to ameliorate areas of soft tissue defect.19 There is no prior experience with injections into the lung parenchyma in animals or humans, although there is a single case report of intrabronchial injection for closure of a tracheal-esophageal fistula.20

These injections were performed using either a standard 5.3-mm outer diameter (OD) video bronchoscope (Model BF-160; Olympus Corporation) or hybrid 4.0-mm OD video bronchoscope (Model BF-MP160F; Olympus Corporation) in airways that were, on average, seven generations beyond the main bronchi. Figure 1 shows the characteristics of Radiesse in an explanted fixed canine lobe and on a prepared hematoxylin and eosin (H&E) slide.

Figure Jump LinkFigure 1 –  A-C, Observations of a Radiesse target in an excised and formalin-fixed lobe (A), on a hematoxylin and eosin histology slide at ×10 magnification (B), and a close-up of the same slide at ×400 magnification showing target spheres (green arrows) (C).Grahic Jump Location

The Radiesse aliquot of 0.25 cc is representative of a solitary pulmonary nodule of at least 8 mm in largest dimension and persists for at least 7 weeks for CT scan observation and sampling using standard biopsy forceps. The presence of Radiesse is detectable via standard histologic processing (such as paraffin imbedding), distinguishable using standard stains, such as H&E, and observable using light microscopy. The Radiesse implantation appears to be localized to the area of injection. Radiesse is observable microscopically by the presence of calcium spheres or related structures in the sampled tissue and has not been observed, via pathologic evaluation, to disperse in the lung parenchyma (Fig 1). The Radiesse-derived lung nodules were below the level of detection of standard fluoroscopy but visible on chest CT scan (Fig 2). This model approximates the clinical scenario of the characteristic subcentimeter nodule detected on chest CT scans obtained for lung cancer screening in high-risk patient populations.

Figure Jump LinkFigure 2 –  Observation of Radiesse targets via CT scan and fluoroscopy. A, anterior-posterior (A-P) CT scan view with slice through two Radiesse targets (of four in subject) indicated by green arrows in the right and left lower lobes, respectively. B, A-P fluoroscopic view of same subject. Note four, 5-mm long by 0.8-mm outer diameter, gold fiducials placed in the lobes of this subject, two in the right lower lobe with a major axis dimension of 8 and 14 mm and two in the left lower lobe with a major axis dimension of 6 mm and 9 mm.Grahic Jump Location
BTPNA Procedure Planning

After implantation of Radiesse targets, CT scans were acquired and plans were generated to prescribe a vessel-free, straight-line path from the central airway POE location directly to the target using the BTPNA image guidance system.

BTPNA Procedure

The nodule access procedure was performed as previously described.16 Bronchoscopic access was initiated with a 2.8-mm working channel, 6.0-mm OD video bronchoscope (Model BF-1T160; Olympus Corporation) through a 10-mm endotracheal tube. Navigation was directed via virtual bronchoscopic navigation along the preoperatively planned route to the target’s entry location. The software provided guidance for the specific bronchoscopic location and orientation for penetration. At the POE, the procedure proceeded as follows: (1) an 18-gauge needle (FleXNeedle; Broncus) was used to pierce the airway wall; (2) a balloon catheter (4.0 mm OD × 6.0 mm length) was inserted into the opening and inflated to 10 atmospheres. The balloon remained in the inflated position for 5 s to enlarge the opening; (3) a 2.0-mm working channel sheath was advanced into the enlarged opening; (4) the balloon was withdrawn and the sheath was locked to a 15-gauge stylet, and together they were advanced to the lesion under fused CT scan/fluoroscopic guidance. The completion of this sequence resulted in a parenchymal “tunnel” that enabled nodule access with 2.0-mm compatible tools after the stylet was withdrawn and while the sheath remained in place.

After penetration and prior to advancement of the sheath through the parenchyma, positioning was confirmed by overlaying CT scan-defined targets and tunnels onto the live fluoroscopy. As the C-arm unit was repositioned, the fused fluoroscopy view was updated in real time. This allowed for confirmation of the tunnel positioning in multiple imaging planes, alleviating the difficulties that can arise when interpreting two-dimensional fluoroscopic projections.

After advancing the sheath to the targets, transbronchial biopsies were performed using a standard 2-mm Olympus biopsy forceps (Fenestrated Rat Tooth Alligator Jaw, Model FB-52C-1), thus providing sufficiently large tissue samples for histologic analysis. Transbronchial lung biopsy samples were fixed in formalin and paraffin-embedded for processing for histologic analysis and then were sectioned and stained, generating histology slides for examination and identification of the target material. Canine subjects were monitored closely for safety of the procedure, including the presence and severity of intraprocedural bleeding and the incidence of pneumothorax on fluoroscopy. In addition, data were collected on the duration of the procedure, the length of the generated tunnels, and the success of bronchoscopic sampling of the targeted simulated nodules.

In nine canines, the BTPNA procedure was performed, and biopsy forceps were used through the sheath to sample 31 individual targets (Fig 3, Table 1). The mean length of the 31 tunnels from the POE on the airway wall to the target was 35 mm (range, 20.5-50.3 mm), and the tunnels terminated at a distance of 8.0 mm (range, 0.1-21 mm) from the pleural surface. The size of the targeted lesions ranged from 5 to15 mm in long-axis diameter, with a mean target diameter of 9.5 mm (95% CI, 4.8-14.1). Mean tunnel creation time was 16:52 min. The diagnostic yield of the BTPNA procedure was 90.3%, as defined by histologic confirmation of CaHA within the biopsy specimen on H&E staining. Figure 1 shows the calcium hydroxylapatite within normal lung parenchyma of a biopsy specimen. The three nondiagnostic biopsy specimens were obtained from 8- and 9-mm nodules in the right lower lobe and an 11-mm diameter nodule in the left lower lobe. Mean number of transbronchoscopic lung biopsies per site was three (range, one to five). No significant adverse events were noted in any of the canine subjects status post BTPNA, with no pneumothoraces and minimal bleeding (all bleeding events were < 2 mL in volume). The absence of pneumothoraces was confirmed by serial intraprocedural and postprocedural fluoroscopy as well as by clinical examination.

Figure Jump LinkFigure 3 –  Aggregate target distribution from the nine animals accessed to examine yield. Targets are collectively overlaid on a single LungPoint virtual fluoroscopic view. Outlines indicate target borders, as viewed from a standard anterior-posterior viewing angle and shown with the point of entry (POE) (indicated by a circle) and a straight line access from the POE to the target. Green targets indicate positive yield and red indicates a negative yield. A 20-mm line (orange) is provided for reference.Grahic Jump Location
Table Graphic Jump Location
TABLE 1 ]  Results of BTPNA Procedure

BTPNA = bronchoscopic transparenchymal nodule access; H:M:S = h:min:s; LLL = left lower lobe; RLL = right lower lobe; RUL = right upper lobe.

Over the past decade, a variety of novel bronchoscopic guidance technologies have been developed and implemented in clinical practice with the aim of improving the diagnosis of peripheral pulmonary lesions. The initial foray into this area was the development of radiologic software that could take data obtained from thin-cut collimation chest CT scan to create three-dimensional reconstructions of the central and peripheral tracheobronchial tree and “fly-through” intraluminal imaging that provided a “virtual bronchoscopy” (VB). The VB images could be used to guide the bronchoscopist to a peripheral nodule by providing a pathway to the lesion but could not provide real-time feedback for confirmation of successful localization.13 Around the same time frame, miniaturization of ultrasound technology facilitated the development of radial ultrasound probes of varying diameters that could be advanced into the distal airways through the working channels of flexible videobronchoscopes for localization of peripheral pulmonary lesions. These radial ultrasound probes could be combined with disposable guide sheaths to allow for reliable and repeated passage of diagnostic devices into the area of the nodule as well as with VB to decrease procedural time and improve diagnostic yield. This technology, however, remains limited by the lack of real-time feedback for nodule localization with the diagnostic device.13

Electromagnetic navigation technologies were a significant advance in bronchoscopic access of peripheral lung lesion, combining virtual bronchoscopy techniques with steerable guides and global-positioning-like software to allow for localization of peripheral lung lesions within an electromagnetic field generated around the patient.21 Newer versions of electromagnetic bronchoscopy allow for localization of both the steerable guide and the sampling devices, improving real-time feedback.

All of these novel navigational bronchoscopic modalities are limited by the requirement for acquisition of tissue samples via the airways. If the target lesion is not directly accessible via the airway, then the likelihood of success of VB, radial-probe, and/or electromagnetic bronchoscopy is significantly decreased.3,13 The yield of “standard” navigational bronchoscopic approaches is also diminished by target lesions that are < 2 cm in diameter.14 Therefore, there is a significant clinical need for a bronchoscopic technology that is able to successfully access and diagnose small peripheral lung lesions that do not directly communicate with an airway.

In general medical practice, such small lesions would be approached with CT scan-guided transthoracic needle biopsy, with diagnostic yields of up to 90% in some series. However, transthoracic needle biopsy is associated with a significant pneumothorax rate of up to 20%, and also has declining success rates of biopsy when target lesions are < 1 to 2 cm in diameter.6

Our group has previously described the BTPNA technique,16 which uses a commercial VB system: LungPoint VBN (Broncus)15 to provide guidance to specific targets through multiple airway generations by the use of image processing without the use of electromagnetic sensors. This VB system is combined with devices designed to provide safe transbronchoscopic access to the lung parenchyma, originally developed for the treatment of severe emphysema (“airway bypass”).22 TPNA software algorithms automatically generate POE recommendations, register CT and real-time fluoroscopic images, and overlay guidance onto live bronchoscopic and fluoroscopic video.16 In our previous report, we demonstrated that BTPNA is feasible in a canine model with very low complication rates and can provide access via a transbronchial route to fiducial targets in the lung parenchyma with high levels of accuracy and close proximity.

In the preclinical study described in this article, we further describe the findings of 31 TPNA procedures in nine canines with novel, simulated pulmonary nodules < 1 cm in diameter. This is the first description in the medical literature to our knowledge of the development of a simulated pulmonary nodule using a substance—Radiesse, a US Food and Drug Administration-approved dermatologic volumizing filler composed of synthetically produced smooth CaHA microspheres—that allows for bronchoscopic sampling and biopsy with standard forceps. Detection of calcium spheres or related structures in the sampled tissue in the preclinical canine model served as the surrogate for a histologic diagnosis in a patient with a peripheral lung lesion of similar location and dimensions. Previous simulated lung nodule animal models primarily consisted of phantoms that could facilitate imaging on chest radiograph, fluoroscopy, or chest CT scan but did not allow for concomitant biopsy via standard bronchoscopic techniques.17,18 It is important to note that the Radiesse simulated pulmonary nodules have a nearly invisible fluoroscopic signature, which corresponds to the characteristics of subcentimeter pulmonary nodules that are likely to be detected on chest CT screening (Fig 2).

There are several important clinical implications pertaining to the results of this preclinical study. The success rate of biopsy of TPNA in this cohort was 90%, as confirmed by independent pathology review. This diagnostic rate is equivalent to that of the best outcomes of TTNA in the medical literature, with the caveat that TTNA is less successful in achieving a diagnosis from parenchymal lesions < 1 cm in diameter. For this reason, the diagnostic rates in this small study likely exceed those of TTNA and certainly are superior to any prior reports of other navigational bronchoscopy techniques targeting nodules < 1 cm.14 In addition, the safety profile of BTPNA found here is superior to that of TTNA, with minimal bleeding and no pneumothoraces, despite a procedure that involves needle puncture, a balloon dilation of the airway wall, and creation of a tunnel through the lung parenchyma with a sheath and stylet, followed by passage of bronchoscopic forceps through the sheath to obtain transbronchoscopic biopsies of the target lesion in the lung parenchyma. The safety profile of the BTPNA procedure appears at least equivalent to that of other navigational bronchoscopy techniques, and to that of standard transbronchoscopic biopsy.13

There are, however, several limitations to the interpretation of the results of this preclinical study. Of primary concern is the small sample size. We include herein the results of the BTPNA procedure in only nine canines, albeit with a total of 31 TPNA-guided biopsies of simulated lung nodules. It is certainly possible that the diagnostic accuracy of the procedure would decrease and the complication rate increase if we included larger numbers of canines and increased the number of nodule targets in the study. Also, the lung parenchyma of the dogs was presumably disease-free, such that pneumothorax rates might be higher in humans with diseased lungs (eg, emphysema). In addition, the BTPNA procedures were performed by engineers who designed the procedure and helped establish this experimental model of the simulated nodule. It is possible that the diagnostic success of the procedure would be decreased in the hands of physicians less familiar with the technology and with the experimental protocol, although experienced interventional pulmonologist are more facile with advanced bronchoscopic procedures in general. In terms of the actual diagnosis of peripheral lung lesions by BTPNA, success of the biopsy procedure in this protocol was determined by documentation of the presence of Radiesse. In real-life scenarios, transbronchoscopic biopsies of a peripheral lung lesion must contain sufficient cellular material to not only determine the presence of malignancy but also allow for immunohistochemical staining to determine the origin of the malignancy (ie, primary pulmonary or metastatic). In addition, increasingly, adequate tissue must be obtained to be able to assess for the presence of gene mutations and other molecular abnormalities that are critical for guidance of targeted systemic therapies. As there is no reliable large animal model of peripheral lung cancer, it is not currently possible to assess the performance of these capabilities of BTPNA-guided biopsy aside from proceeding with a human clinical trial.

In summary, we report herein the first report to our knowledge in a preclinical animal model of safe and accurate transparenchymal navigated bronchoscopy with access to—and successful biopsy of—simulated, small, intraparenchymal pulmonary nodules. Combined with previous reports, these canine studies demonstrate that BTPNA has the potential to achieve the high yield of TTNA with the low complication profile associated with traditional bronchoscopy. As demonstrated in this follow-up preclinical study, BTPNA has the ability to access small peripheral nodules in the absence of a documented CT scan bronchus sign, including nodules in close proximity to the pleura, which are difficult to perform a biopsy on successfully with TTNA. Additionally, sufficiently large, transbronchoscopic lung biopsies can be obtained via BTPNA to allow for formal histologic analysis of the specimens. Given the documentation of the provision of high-accuracy transparenchymal access to peripheral lung lesions with very low complication rates, there is also the future potential for delivering therapeutics via this approach with the goal of definitive treatment of small, peripheral lung cancers. This emerging novel bronchoscopic technology merits further study in humans to more formally assess the feasibility, safety, and diagnostic capabilities of this new technology.

Author contributions: D. H. S. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. D. H. S., F. J. H., and G. A. S. participated in the design of the trial, analysis of the results, and writing of the manuscript; D. H. S., T. K., L. R., J. G., H. W., and J. D. performed the experiment and participated in the design and analysis of the data; and T. K., L. R., J. G., H. W., and J. D. participated in the writing and revision of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Silvestri, Sterman, and Herth have received consulting fees from Broncus. Dr Sterman received travel support for conduct of this study. Drs Silvestri and Herth have received grant funding for this and other studies performed for Broncus. Messrs Keast, Wibowo, and Draper and Drs Rai and Gibbs are employees of Broncus.

BTPNA

bronchoscopic transparenchymal nodule access

CaHA

calcium hydroxylapatite

H&E

hematoxylin and eosin

OD

outer diameter

POE

point of entry

TPNA

transparenchymal nodule access

TTNA

transthoracic needle aspiration

VB

virtual bronchoscopy

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Figures

Figure Jump LinkFigure 1 –  A-C, Observations of a Radiesse target in an excised and formalin-fixed lobe (A), on a hematoxylin and eosin histology slide at ×10 magnification (B), and a close-up of the same slide at ×400 magnification showing target spheres (green arrows) (C).Grahic Jump Location
Figure Jump LinkFigure 2 –  Observation of Radiesse targets via CT scan and fluoroscopy. A, anterior-posterior (A-P) CT scan view with slice through two Radiesse targets (of four in subject) indicated by green arrows in the right and left lower lobes, respectively. B, A-P fluoroscopic view of same subject. Note four, 5-mm long by 0.8-mm outer diameter, gold fiducials placed in the lobes of this subject, two in the right lower lobe with a major axis dimension of 8 and 14 mm and two in the left lower lobe with a major axis dimension of 6 mm and 9 mm.Grahic Jump Location
Figure Jump LinkFigure 3 –  Aggregate target distribution from the nine animals accessed to examine yield. Targets are collectively overlaid on a single LungPoint virtual fluoroscopic view. Outlines indicate target borders, as viewed from a standard anterior-posterior viewing angle and shown with the point of entry (POE) (indicated by a circle) and a straight line access from the POE to the target. Green targets indicate positive yield and red indicates a negative yield. A 20-mm line (orange) is provided for reference.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Results of BTPNA Procedure

BTPNA = bronchoscopic transparenchymal nodule access; H:M:S = h:min:s; LLL = left lower lobe; RLL = right lower lobe; RUL = right upper lobe.

References

Gould MK, Fletcher J, Iannettoni MD, Lynch WR, Midthun DE, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3_suppl):108S-130S. [CrossRef] [PubMed]
 
Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3_suppl):94S-107S. [CrossRef] [PubMed]
 
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