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Robotic-Assisted Navigation Bronchoscopy as a Paradigm Shift in Peripheral Lung Access

Abstract

Introduction

The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation.

Methods

52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained.

Results

Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was < 2 cm in all dimension with the majority solid (41, 70%) and located in the upper lobes (left: 22, 37%; right: 17, 29%). Bronchus sign was absent (32, 54%) or present (27, 46%) in a similar number. All nodules were successfully reached with nine (15%) requiring minor directional changes after initial cone beam CT. A tissue diagnosis was obtained in 83% (49/59) of biopsied nodules, with malignancy (31, 65%) most common. Including all biopsy results and follow-up imaging, we obtained an 84% (31/37) procedural sensitivity for malignancy and an overall 86% (51/59) diagnostic yield.

Conclusion

RANB with CBCT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies. Combining these modalities has the potential to shift the diagnostic approach to pulmonary nodules.

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Abbreviations

CBCT:

Cone beam CT

ENB:

Electromagnetic navigation bronchoscopy

EBUS:

Endobronchial ultrasound

EBUS-TBNA:

Endobronchial ultrasound-guided transbronchial needle aspiration

IP:

Interventional pulmonology

LLL:

Left lower lobe

LUL:

Left upper lobe

PAMF:

Palo Alto Medical Foundation

PEEP:

Positive end expiratory pressure

REBUS:

Radial endobronchial ultrasound

RLL:

Right lower lobe

RML:

Right middle lobe

RUL:

Right upper lobe

RANB:

Robotic-assisted navigation bronchoscopy

TTNA:

Transthoracic needle aspiration

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Funding

The authors report funding in part from an El Camino Foundation clinical research grant (GK). The study sponsors had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The corresponding author confirms that he had full access to all the data in the study and has final responsibility for the decision to submit for publication. A University of Nevada Las Vegas Faculty Development Leave supported interventional pulmonology fellowship training for AOR.

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Contributions

BSB, AOR, ML, and GK were responsible for data collection and accuracy of data and contributed to analysis of results, finalization of the manuscript, and approval of the submitted article. BSB and GK conceived and wrote the manuscript and take responsibility for the integrity of the work as a whole. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Bryan S. Benn.

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Conflict of interest

BSB and GK have received consulting fees from Intuitive for work unrelated to this study. AOR and ML declare no conflicts of interest or other disclosures.

Ethical Approval

Approval was obtained from the institutional review board of Palo Alto Medical Foundation #1014791-6.

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Benn, B.S., Romero, A.O., Lum, M. et al. Robotic-Assisted Navigation Bronchoscopy as a Paradigm Shift in Peripheral Lung Access. Lung 199, 177–186 (2021). https://doi.org/10.1007/s00408-021-00421-1

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Keywords

  • Lung nodule
  • Robotic bronchoscopy
  • Cone beam CT
  • Lung cancer