Procedures: Procedures 1 - EMN/BT/Rigid/Cryo |

Electromagnetic Navigation Bronchoscopy Paired With Cone-Beam CT Confirmation for Biopsy of Difficult Peripheral Lung Lesions: A Prospective Pilot Trial FREE TO VIEW

Louis Lam, MD; Thomas Gildea, MD; Michael Machuzak, MD; Yvonne Meli, RN
Author and Funding Information

Cleveland Clinic, Cleveland, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1005A. doi:10.1016/j.chest.2016.08.1111
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SESSION TITLE: Procedures 1 - EMN/BT/Rigid/Cryo

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: The purpose of this study is to examine the added value of performing electromagnetic navigation bronchoscopy (ENB) with cone-beam CT confirmation for biopsy of small, peripheral lung lesions.

METHODS: This study is a prospective pilot trial open to patients with peripheral lung lesions > 5 mm and < 30mm who are referred for ENB. Bronchoscopy is performed under generalized anesthesia in the interventional radiology suite with an Artis Zeego (Siemens) robotic-arm, cone-beam CT scanner. All cases are reviewed by our advanced diagnostic bronchoscopy team to determine appropriateness for undergoing ENB. A pre-procedure CT scan is obtained for ENB planning using a superDimension (Covidien) navigation system. Following a routine airway examination, electromagnetic navigation registration and peripheral navigation is performed -with navigation success being defined as a straight on path sufficient for biopsy. Radial endobronchial ultrasound is used to confirm location relative to the target lesion after which a biopsy instrument is deployed. The bronchoscope is then affixed into position and a Cone-beam CT scan is performed to confirm the location of the biopsy instrument relative to the target lesion. Biopsies are taken using a combination of transbronchial needle aspirations, routine cytology brushes, single/triple needle brushes, washings, and forceps biopsies. Rapid on-site examination (ROSE) is used to ensure adequacy of cytology specimens. Variables that are collected for the study include basic patient demographics, size and location of target lesion (lobe and distance to pleura), navigation time, total procedure time, total radiation exposure, navigational success, successful placement of biopsy instrument into target lesion, and final diagnostic yield.

RESULTS: We enrolled eight subjects with small, peripheral lung nodules into this pilot trial. Four subjects had a target nodule in the right upper lobe, three in the left upper lobe, and one in the right lower lobe. The average nodule size was 13.4 mm (range of 7 to 23 mm). Navigation success was universal for all eight procedures. Successful placement of a biopsy instrument into the target nodule was confirmed by cone-beam in 7 of the 8 cases. Definitive diagnosis of malignancy was made in three cases with one additional cases being highly suspicious for malignancy. Fiducial marker placement was performed in two cases with confirmation of placement using cone-beam CT.

CONCLUSIONS: Cone-beam CT can be used to confirm placement of biopsy instruments during ENB. However, despite having optimal positioning of the biopsy instrument, diagnostic yield is still not guaranteed.

CLINICAL IMPLICATIONS: This pilot trial demonstrates that cone-beam CT can be effectively paired with ENB. This combination may be applied to any bronchoscopic procedure requiring precision placement of instruments into the lung periphery and can perhaps be used as a stepping-stone for future therapeutic techniques such as radiofrequency ablation of small tumors.

DISCLOSURE: Thomas Gildea: Consultant fee, speaker bureau, advisory committee, etc.: Medtronic, Grant monies (from industry related sources): Siemens Michael Machuzak: Consultant fee, speaker bureau, advisory committee, etc.: Olympus The following authors have nothing to disclose: Louis Lam, Yvonne Meli

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