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G. Avignon

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    MINI 19 - Surgical Topics in Localized NSCLC (ID 138)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 1
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      MINI19.09 - Adjunct Intraop Cone Bean CT (CBCT) with Real Time 3D Overlay Improves Diagnostic Accuracy of Electromagnetic Navigational Bronchoscopy (ENB) (ID 1078)

      16:45 - 18:15  |  Author(s): G. Avignon

      • Abstract
      • Presentation

      ENB is limited by diagnostic accuracy of 60-80%[ [1]]. We hypothesize that using intraoperative CBCT with real time 3D overlay onto fluoroscopic images to confirm placement of biopsy tools in the lesion will increase the diagnostic accuracy of ENB biopsies. [1] Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-Analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule. Chest. 2012;142(2):385-393. doi:10.1378/chest.11-1764

      Patients with undiagnosed small pulmonary nodules (<20 mm) underwent biopsy where an initial CBCT of the chest under breath hold was performed, followed by a 3D model reconstruction of the lesions while the surgeon started the ENB. At the end of the bronchoscope navigation, the 3D model of the lesion was fused and automatically registered in real time over the 2D fluoroscopy, allowing an evaluation of the biopsy tool positioning in 3-dimensions. Multiple samples were collected after confirmation of the tool position using various oblique views. Figure 1

      In our initial experience with 10 cases, CBCT acquisition, reconstruction and 3D-overlay was successful in all cases. This procedure enabled confirmation of biopsy tool position within the target lesion in all cases. In one case, the new information obtained successfully discriminated a diaphragm implant from what previously had been interpreted as a basilar parenchymal nodule. In a second case, CBCT reconstruction enabled biopsy of a 15mm lesion thought to be a solitary metastasis. The biopsy was interpreted as normal, albeit in clinical circumstances which were suspicious for malignancy. The patient elected non-surgical treatment of an esophageal primary, precluding definitive pathologic confirmation. A third case provided a biopsy interpreted as normal in a patient who ultimately proceeded to resection for growth of the nodule. While frozen section suggested a benign entity, final pathology demonstrated scattered elements of malignancy. In the remaining cases, CBCT and 3D overlay assisted in successful and accurate biopsy of nodules <20mm.

      Intraoperative CBCT and real time 3D overlay onto fluoroscopic images to confirm appropriate positioning of the biopsy tools in the lesion during ENB is technically feasible. It effectively combines the advantage of real time CT imaging with the advantages of ENB biopsy. This has the potential to increase the diagnostic accuracy of ENB aided tissue diagnosis of small pulmonary nodules. This novel technique will facilitate early accurate diagnosis of lung cancer in small nodules with a minimally invasive approach.

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