Walter Reed National Military Medical Center, Silver Spring, MD
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Fellow Case Report Slide: Procedures
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM
INTRODUCTION: Bronchoscopic trans-parenchymal nodule access (BTPNA) is a novel endoscopic technique that creates a virtual pathway to the lesion and is less limited by location of the airway. The BTPNA uses a balloon catheter equipped guide sheath for a trans-parenchymal approach to the lesion. In a porcine model the CrossCountry TM trans-bronchial access tool was compared to existing BTPNA endoscopic needle with a balloon dilator. The device was successful in creating an airway exit point and tunneling to the target lesion via the parenchyma with no greater risk compared to sham device.
CASE PRESENTATION: An 88 year old man with COPD and 100 pack year tobacco history was referred to our clinic after a chest CT showed two PET avid nodules in the right middle and right lower lobe and small focus of FDG avidity in right and left hilum. The right lower lobe was confirmed with CT guided biopsy to be squamous cell carcinoma (SCC). The right middle lobe nodule, although pleural based, was deemed inaccessable by CT guided biopsy. The patient underwent a bronchoscopy. EBUS guided biopsy of stations 7 and 11R was benign. The endobronchial path to the target was determined using navigational software and the catheter navigated to within 3 cm of the right middle lobe lesion. The sensor was positioned within the linear plane to the lesion under cone-beam CT guidance, but could not be advanced further. A CrossCountryTM tool was inserted and a needle advanced towards the lesion. Cone-beam CT showed the needle was centerd within the lesion. A dilator was advanced over the wire and position was confirmed with cone-beam CT. The catheter was advanced through the tract and position was confirmed with radial ultrasound. Biopsies were performed and returned SCC.
DISCUSSION: The evidence of the potential role of BTPNA is expanding. We demonstrate a case where trans-bronchial access tool was instrumental in locasliztion of a lesion despite the lack of a direct airway. To our knowledge there are currently no head to head trials or cases comparing electromagnetic navigational bronchoscopy, CT-guided biopsy and trans-bronchial access tools.
CONCLUSIONS: Despite not currently being standard of care the trans-bronchial access tool increased diagnostic yield in this case and will likely have a greater clinical impact on interventional bronchoscopy.
Reference #1: Bolton W, Krimsky W, et al. Performance of a Novel Off-Airway Access Tool for Peripheral Lung Navigation in a Porcine Lung Model. Am J Respir CritCare med 191;2015:A3064
DISCLOSURE: William Krimsky: Consultant fee, speaker bureau, advisory committee, etc.: Dr. Krimsky served as a consultant for Medtronic The following authors have nothing to disclose: Michal Sobieszczyk, Sy Sarkar, Mohammed Nabeel
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