Pulmonary Perspectives® New Technology Enhances Electromagnetic Navigation Bronchoscopy
Our institution incorporated this technology (Veran Medical, St. Louis) into our advanced diagnostic and interventional pulmonary program for lung nodules and published our initial experience and results. During the initial 8 months of screening for lung cancer, we performed procedures on 44 patients with PNs suspicious for lung cancer. The rate for successful target sampling was 90.2% with a cancer diagnosis rate of 39%, which is similar to that found in the NLST. Those patients who had nonmalignant but abnormal pathologic findings (inflammation, granuloma, fibrosis, and so on) were monitored for a minimum of 12 months. Most of the lesions either remained stable or disappeared on follow-up imaging (Flenaugh et al. The Internet Journal of Pulmonary Medicine. 2016;18[1]). We concluded that (1) the combination of paired inspiratory and expiratory CT scan imaging accounts for nodule movement and (2) using tip-tracked conventional instruments to enter into the lesion at the time of biopsy contributes to improved yields.
Newer ENB technology is not limited to transbronchial sampling. For PNs less than 2 cm and deep in the lung periphery, current recommendations prefer TTNA over bronchoscopic biopsy because of yield rates of 90% (Chest. 2007; 132(suppl 3):131S). Using the same paired CT scanning and tip-tracking method on transthoracic needles, the new systems allow pulmonologists to perform electromagnetic transthoracic needle aspiration (ETTNA) of PNs using the same basic equipment and during the same procedure visit (Fig. 4). This “one stop shopping” approach of bronchoscopy with the option of converting to ETTNA if the PN is not reachable endoscopically has proven to be cost efficient and allows for timely diagnosis and focused care (Yarmis et al. J Thorac Dis. 2016;8(1):186). In a prospective study designed specifically to assess feasibility, safety, and diagnostic yield of ETTNA in a single procedure, Yarmis and colleagues enrolled 24 patients to undergo endobronchial ultrasound for lung cancer staging followed by ENB and ETTNA. Ninety-six percent of the patients were candidates for ETTNA. The authors reported the yield for ETTNA was 83%, ETTNA plus ENB 87%, and ETTNA plus ENB plus endobronchial ultrasound for complete staging was 92%. Five pneumothoraces were reported; however, only two (8%) required a drainage intervention. This protocol is unique because it makes use of several advanced diagnostic procedures, including tip-tracked navigation technology, to localize, sample, diagnose, and stage during one patient procedure visit.
As lung cancer screening becomes commonplace in clinical practice and imaging technology improves, pulmonary specialists can expect to encounter and manage a greater number of pulmonary nodules. Advancements in technology now offer options for improving diagnostic accuracy while providing timely, safe, and cost effective care. While not all new technology will prove beneficial in disease management, those that improve the deficiencies of earlier technology offer us the best chance to improve practice. This perspective highlights such technology.
Dr. Flenaugh is Associate Professor, Director of Advanced Diagnostic & Interventional Pulmonary Service,Morehouse School of Medicine and Grady Hospital, Atlanta; Dr. Foreman is Professor of Medicine, Associate Chair for Research, Pulmonary & Critical Care Medicine, Morehouse School of Medicine.
