State of the art: peripheral diagnostic bronchoscopy

Abstract

Lung cancer is the leading cause of cancer related death worldwide and in the United States according to the World Health Organization and National Cancer Institute. Improvements in the diagnosis and treatment of lung cancer are of the utmost importance. A prompt diagnosis is a crucial factor to improve outcomes in the treatment of lung cancer. Although the implementation of lung cancer screening guidelines and the overall steady growth in the use of computed tomography have improved the likelihood of detecting lung cancer at an earlier stage, the diagnosis of peripheral pulmonary lesions (PPLs) has remained a challenge. The bronchoscopic techniques for PPL sampling have historically offered modest diagnostic yields at best in comparison to computed tomography guided transthoracic needle aspiration (TTNA). Fortunately, recent advances in technology have ushered in a new era of diagnostic peripheral bronchoscopy. In this review, we discuss the introduction of advanced intraprocedural imaging included digital tomosynthesis (DT), augmented fluoroscopy (AF), and cone beam computed tomography. We discuss robotic assisted bronchoscopy with a review of the currently available platforms, and we discuss the implementation of novel biopsy tools. These technologic advances in the bronchoscopic approach to PPLs offer greater diagnostic certainty and pave the way toward peripheral therapeutics in bronchoscopy.

Keywords: Peripheral pulmonary lesion (PPL); cone beam computed tomography (CBCT); diagnostic bronchoscopy; robotic-assisted bronchoscopy (RAB).

Figure 1

Example of intraoperative use of CBCT to confirm TIL. (A) CBCT imaging shows the target ground glass nodule (asterisk) and a large adjacent blood vessel (arrow). (B) Prior to obtaining a biopsy, re-imaging was performed to visualize the tip of the biopsy instrument relative to the target nodule (asterisk) and blood vessel. Sampling confirmed adenocarcinoma. (C) CBCT imaging revealed the biopsy instrument to be tangential to the target lesion (circle). On-site cytologic evaluation was non-diagnostic. (D) After adjusting the instrument and re-imaging, TIL confirmation was obtained. On-site cytologic evaluation of sample from target lesion (circle) showed adenocarcinoma. Images courtesy of Brian D. Shaller. CBCT, cone beam computed tomography; TIL, tool-in-lesion.

Figure 2

CT-like images rendered via digital tomosynthesis using (A) the LungVision system (BodyVision Medical, Campbell, CA, USA) and (B) the Galaxy robotic-assisted bronchoscopy platform (Noah Medical, San Carlos, CA, USA). Images courtesy of Joesph Cicenia. CABT, C-arm based tomography; AI, artificial intelligence; LAO, left anterior oblique; RAO, right anterior oblique; CT, computed tomography.

Figure 3

Representative images of augmented fluoroscopy. (A) Augmented fluoroscopy with the LungVision system (BodyVision Medical, Campbell, CA, USA), showing the regional airways (blue lines), suggested navigation pathway (pink line), and target lesion (yellow circle). Image courtesy of Joesph Cicenia. (B) Augmented fluoroscopy using a fixed cone beam CT system (Philips, Amsterdam, The Netherlands). Owing to the gradual development of atelectasis, the radio-opaque lesion (arrow) has changed position relative to where it was on cone beam CT imaging only a few minutes prior, while its virtual representation (asterisk) remains static. Image courtesy of Brian D. Shaller. CT, computed tomography.