Diagnosing peripheral lung lesions using endobronchial ultrasonography with guide sheath: A prospective registry study to assess the effect of virtual bronchoscopic navigation using a computed tomography workstation

Abstract

Bronchoscopy has a lower diagnostic yield for peripheral lung lesions (PLL). Endobronchial ultrasound guide sheath transbronchial lung biopsy (EBUS GS TBLB) has been used to overcome such limitation. Recent studies revealed that combined methods (e.g., EBUS GS TBLB plus electromagnetic navigation [EMN] or virtual bronchoscopic navigation [VBN]) further improve the diagnostic yield. However, those systems are associated with a high cost burden. Accordingly, we attempted to use VBN by computed tomography (CT) workstation (Aquarius iNtuition, TeraRecon) not dedicated only for VBN as an adjunctive tool for EBUS GS TBLB. We performed a prospective registry study to investigate whether VBN by CT workstation could improve the diagnostic yield of PLL.Between February 2017 and February 2018, 128 patients with PLL were divided into 2 groups (VBN and non-VBN [NVBN]). In NVBN group (n = 64), EBUS GS TBLB was performed using a hand-drawn bronchial map based on CT images. VBN group (n = 64) underwent EBUS GS TBLB using VBN images.VBN using CT workstation did not improve the diagnostic yield of EBUS GS TBLB for PLL (VBN vs NVBN, 72% vs 80%, P = .284). VBN slightly reduced procedure time (minute [mean ± SD], 25.31 ± 10.33 vs 25.81 ± 9.22), navigation time (time to find the lesion) (9.10 ± 7.88 vs 9.50 ± 7.14), and fluoroscopy time (2.23 ± 2.39 vs 2.86 ± 4.61), while these differences were not statistically significant.The diagnostic yield of EBUS GS TBLB was not improved with VBN (compared with using a hand-drawn bronchial map). Although VBN slightly shortened the procedure-related times, which were not significantly different.

Figure 1

VBN image-creation process. Radiologist processes CT acquisition data to VBN images (the right upper area of the figure) with a high-performance workstation (Aquaris iNtuition, TeraRecon, Foster City, CA). CT = computed tomography, VBN = virtual bronchoscopic navigation.

Figure 2

Diagrammatic representation of the present study. VBN (n = 64) and NVBN groups (n = 64) were equally randomized. EBUS GS TBLB was conducted in all patients. Ten patients were excluded from diagnostic yield analysis because of the lack of final diagnosis: 4 (2 each from the VBN and NVBN groups) refused further work-up (TTNA or surgical biopsy) after failing EBUS GS TBLB (non-visualization on EBUS or failed TBLB), and 6 (VBN group [n = 5], NVBN group [n = 1]), who were diagnosed with non-malignant pathology using EBUS GS TBLB, were not followed-up. Of the remaining 118 patients, 90 (76%) had a positive diagnostic result via EBUS GS TBLB and the remaining 28 required a subsequent TTNA or surgical biopsy to establish final histological diagnosis. EBUS GS TBLB = endobronchial ultrasound guide-sheath transbronchial lung biopsy, NVBN = non-VBN, VBN = virtual bronchoscopic navigation.

Figure 3

A representative example of the NVBN group: (A) PLL was located at right upper lobe apical segment on chest CT; (B) hand-drawn bronchial map generated following a detailed examination of chest CT; (C) EBUS visualization of probe within PLL. CT = computed tomography, NVBN = non-VBN; PLL = peripheral lung lesion, VBN = virtual bronchoscopic navigation.

Figure 4

A representative example of the VBN group: (A) Left: PLL was located at the border between anterior and posterior segment of right upper lobe on chest CT, Right: VBN image of right upper lobe. (B) Practical implementation of VBN. The assistant (not visible in the picture) changes the VBN images of the path leading to a PLL according to the actual bronchoscopy images. CT = computed tomography, EBUS GS TBLB = endobronchial ultrasound guide-sheath transbronchial lung biopsy, PLL = peripheral lung lesion, VBN = virtual bronchoscopic navigation.