Electromagnetic Navigation Diagnostic Bronchoscopy in Peripheral Lung Lesions

doi:10.1378/chest.06-3016

Chest

Volume 131, Issue 6, June 2007, Pages 1800-1805

https://doi.org/10.1378/chest.06-3016 Get rights and content

Background

Electromagnetic navigation bronchoscopy (ENB) with biopsy under fluoroscopic guidance has enhanced the yield of flexible bronchoscopy in the diagnosis of peripheral lung lesions. However, the accuracy of ENB navigation suggests that the addition of fluoroscopy is redundant.

Objectives

Data were prospectively collected to determine the yield of ENB without fluoroscopy in the diagnosis of peripheral lung lesions.

Method

ENB was performed via flexible bronchoscopy (superDimension/Bronchus system; superDimension Inc; Plymouth, MN). Biopsy specimens were obtained through the extended working channel after navigation. Fluoroscopy was not utilized, but post-transbronchial biopsy chest radiographs were obtained to exclude pneumothorax. The primary end point was diagnostic yield, and the secondary end points were navigation accuracy, procedure duration, and safety. Analysis by lobar distribution was also performed to assess performance in different lobes of the lung.

Results

Ninety-two peripheral lung lesions were biopsied in the 89 subjects. The diagnostic yield of ENB was 67%, which was independent of lesion size. Total procedure time ranged from 16.3 to 45.0 min (mean [± SD] procedure time, 26.9 ± 6.5 min). The mean navigation error was 9 ± 6 mm (range, 1 to 31 mm). There were two incidences of pneumothorax for which no intervention was required. When analyzed by lobar distribution, there was a trend toward a higher ENB yield in diagnosing lesions in the right middle lobe (88%).

Conclusions

ENB can be used as a stand-alone bronchoscopic technique without compromising diagnostic yield or increasing the risk of pneumothorax. This may result in sizable timesaving and avoids radiation exposure.

Section snippets

Materials and Methods

Eighty-nine patients underwent ENB at our two centers between February 2005 and August 2006. Inclusion criteria were subjects above the age of 18 years, who signed informed consent forms and were candidates for elective bronchoscopy. They all had evidence of peripheral lung lesions or solitary pulmonary nodules with no evidence of endobronchial pathology. Pregnant patients and those with implantable pacemakers or defibrillators were excluded. The institutional review boards of both of the

Results

Ninety-two peripheral lung lesions were biopsied in the 89 subjects, of whom 39 (44%) were female. The mean age was 67 ± 12 years (age range, 29 to 95 years). The mean size of lesions was 24 ± 8 mm (range, 10 to 58 mm); the mean number of forceps biopsies performed was 5 ± 1 (range, 0 to 11). A single patient had no forceps biopsies because the navigation error was 31 mm despite multiple attempts. This was attributed to the possible absence of a bronchus leading to the lesion. The bronchial

Discussion

In this largest series to date, we have shown that ENB can be used as an independent bronchoscopic technique without the need for fluoroscopy when compared with other available studies. There was no compromise in the diagnostic yield and no increased risk of pneumothorax. This yield was attributable to the small registration error (< 5 mm) and navigation error (< 10 mm) that occurred. Our pneumothorax rate (2 of 89 patients; 2%) compares favorably with those of preceding studies,³⁵ in which the

ACKNOWLEDGMENT

Dr. Roger Davis from Department of Medicine, Beth Israel Deaconess Medical Center (Boston, MA) assisted with the statistical analysis. Robert Garland from Interventional Pulmonology, Beth Israel Deaconess Medical Center (Boston, MA) assisted with data collection.

References (23)

G Schreiber et al.
Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence
Chest
(2003)
WA Baaklini et al.
Diagnostic yield of fiberoptic bronchoscopy in evaluating solitary pulmonary nodules
Chest
(2000)
Y Schwarz et al.
Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study
Chest
(2006)
H Hautmann et al.
Electromagnetic catheter navigation during bronchoscopy: validation of a novel method by conventional fluoroscopy
Chest
(2005)
BB Tan et al.
The solitary pulmonary nodule
Chest
(2003)
G Paone et al.
Endobronchial ultrasound-driven biopsy in the diagnosis of peripheral lung lesions
Chest
(2005)
N Kurimoto et al.
Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically
Chest
(2004)
FJ Herth et al.
Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: a prospective trial
Chest
(2006)
PM Suratt et al.
Deaths and complications associated with fiberoptic bronchoscopy
Chest
(1976)
N Sawabata et al.
Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract
Chest
(2000)

KM Yeow et al.

Risk factors of pneumothorax and bleeding: multivariate analysis of 660 CT-guided coaxial cutting needle lung biopsies

Chest

(2004)

Cited by (276)

Comparison of electromagnetic navigation bronchoscopy and transthoracic needle biopsy for diagnosing bronchus sign-positive pulmonary lesions
2023, Lung Cancer
Electromagnetic navigation bronchoscopy (ENB) is an advanced technique for diagnosing peripheral pulmonary lesions, and the bronchus sign is a well-established factor for improving the diagnostic performance. However, ENB is a novel technology compared to the commonly adopted transthoracic needle biopsy (TTNB). There are limited data on the comparison of these techniques for diagnosing bronchus sign-positive lesions. Therefore, we aimed to compare the diagnostic yield and complication rates of ENB and TTNB for diagnosing lung cancer in bronchus sign-positive pulmonary lesions.
We assessed 2,258 individuals who underwent either of the techniques for initial biopsy between September 2016 and May 2022 at a tertiary center in South Korea and analyzed 1,248 participants (153 ENB and 1,095 TTNB cases) with a positive bronchus sign. We performed multivariable logistic regression analyses to evaluate the factors associated with the diagnostic yield, sensitivity for malignancy, and procedure-related complications. In addition, the outcomes were compared between the two techniques after a 1:2 propensity score-matching to control for pre-procedural factors.
After adjustments for clinical/radiological factors, performing TTNB over ENB was not significantly associated with a higher diagnostic yield but with a higher risk of pneumothorax (OR = 9.69, 95% CI = 4.15–22.59). Propensity score-matching resulted in 459 participants (153 ENB and 306 TTNB cases) with balanced pre-procedural characteristics. The overall diagnostic yield did not differ significantly between ENB and TTNB (85.0% vs. 89.9%, p = 0.124). The diagnostic yield (86.7% vs. 90.3%, p = 0.280) and sensitivity for malignancy (85.3% vs. 88.8%, p = 0.361) were comparable among patients with a class 2 bronchus sign. However, TTNB demonstrated a significantly higher complication rate of pneumothorax (28.8% vs. 3.9%, p < 0.001) and pneumothorax requiring tube drainage (6.5% vs. 2.0%, p = 0.034) than ENB.
ENB demonstrated a diagnostic yield comparable with that of TTNB for diagnosing bronchus sign-positive peripheral pulmonary lesions with significantly lower complication rates.
Diagnostic yield and safety of navigation bronchoscopy: A systematic review and meta-analysis
2023, Lung Cancer
Navigation bronchoscopy has seen rapid development in the past decade in terms of new navigation techniques and multi-modality approaches utilizing different techniques and tools. This systematic review analyses the diagnostic yield and safety of navigation bronchoscopy for the diagnosis of peripheral pulmonary nodules suspected of lung cancer.
An extensive search was performed in Embase, Medline and Cochrane CENTRAL in May 2022. Eligible studies used cone-beam CT-guided navigation (CBCT), electromagnetic navigation (EMN), robotic navigation (RB) or virtual bronchoscopy (VB) as the primary navigation technique. Primary outcomes were diagnostic yield and adverse events. Quality of studies was assessed using QUADAS-2. Random effects meta-analysis was performed, with subgroup analyses for different navigation techniques, newer versus older techniques, nodule size, publication year, and strictness of diagnostic yield definition. Explorative analyses of subgroups reported by studies was performed for nodule size and bronchus sign.
A total of 95 studies (n = 10,381 patients; n = 10,682 nodules) were included. The majority (n = 63; 66.3%) had high risk of bias or applicability concerns in at least one QUADAS-2 domain. Summary diagnostic yield was 70.9% (95%-CI 68.4%-73.2%). Overall pneumothorax rate was 2.5%. Newer navigation techniques using advanced imaging and/or robotics (CBCT, RB, tomosynthesis guided EMN; n = 24 studies) had a statistically significant higher diagnostic yield compared to longer established techniques (EMN, VB; n = 82 studies): 77.5% (95%-CI 74.7%-80.1%) vs 68.8% (95%-CI 65.9%-71.6%) (p < 0.001). Explorative subgroup analyses showed that larger nodule size and bronchus sign presence were associated with a statistically significant higher diagnostic yield. Other subgroup analyses showed no significant differences.
Navigation bronchoscopy is a safe procedure, with the potential for high diagnostic yield, in particular using newer techniques such as RB, CBCT and tomosynthesis-guided EMN. Studies showed a large amount of heterogeneity, making comparisons difficult. Standardized definitions for outcomes with relevant clinical context will improve future comparability.
Evaluation of electromagnetic navigational bronchoscopic biopsy of lung lesions performed by a thoracic surgical service
2023, Surgery (United States)
With the increasing use of computed tomography scans for lung cancer screening and surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. Electromagnetic navigational bronchoscopy-guided lung biopsy is a relatively new technique for bronchoscopic biopsy. Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy-guided lung biopsy.
We conducted a retrospective review of patients who underwent an electromagnetic navigational bronchoscopy biopsy, performed by a thoracic surgical service, and evaluated its safety and diagnostic accuracy.
In total, 110 patients (men 46, women 64) underwent electromagnetic navigational bronchoscopy sampling of pulmonary lesions (n = 121; median size 27 mm; interquartile range 17–37 mm). There was no procedure-related mortality. Pneumothorax requiring pigtail drainage occurred in 4 patients (3.5%). Ninety-three (76.9%) of the lesions were malignant. Eighty-seven (71.9%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (P = .0578) with a yield of 50% for lesions <2 cm, increasing to 81% for lesions ≥2 cm. The lesions that demonstrated a positive “bronchus sign” had a yield of 87% (45/52) compared with 61% (42/69) in lesions with a negative “bronchus sign” (P = .0359).
Thoracic surgeons can perform electromagnetic navigational bronchoscopy safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of a bronchus sign and increasing lesion size. Patients with larger tumors and the bronchus sign may be candidates for this approach to biopsy. Further work is required to define the role of electromagnetic navigational bronchoscopy in the diagnosis of pulmonary lesions.
Single Institution Evaluation of Electromagnetic Navigation Bronchoscopy for Diagnosis of Pulmonary Lesions
2024, Journal of Bronchology and Interventional Pulmonology
The effect of combining different sampling tools on the performance of electromagnetic navigational bronchoscopy for the evaluation of peripheral lung lesions and factors associated with its diagnostic yield
2023, BMC Pulmonary Medicine
Outcomes of the electromagnetic navigation bronchoscopy using forceps for lung lesion suspected malignancy: A retrospective study
2023, Medicine (United States)

View all citing articles on Scopus

A portion of these data has been accepted as an abstract for the 2007 American Thoracic Society International Conference.

The locatable sensor probes at both Thoraxklinik and Beth Israel Deaconess Medical Center were provided free of charge by superDimension/Bronchus. superDimension/Bronchus has supported CME courses at the Thoraxklinik Heidelberg and Harvard University through unrestricted educational grants. Dr. Ernst was a member of the Scientific Advisory Board of superDimension/Bronchus and had been reimbursed for time and travel expenses related to that function. Dr. Ernst also had stock options, which have been returned in the past. Dr. Ernst was not involved in the consenting process of patients. Drs. Eberhardt, Anantham, Herth, and Feller-Kopman have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

View full text

Chest

ORIGINAL RESEARCHINTERVENTIONAL PULMONOLOGYElectromagnetic Navigation Diagnostic Bronchoscopy in Peripheral Lung Lesions

Background

Objectives

Method

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENT

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

ORIGINAL RESEARCH
INTERVENTIONAL PULMONOLOGY
Electromagnetic Navigation Diagnostic Bronchoscopy in Peripheral Lung Lesions