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Roel L.J. Verhoeven



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    OA01 - Advanced Diagnostic Approaches for Intrathoracic Lymph Nodes and Peripheral Lung Tumors (ID 117)

    • Event: WCLC 2019
    • Type: Oral Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 2
    • Now Available
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      OA01.01 - Predictive Value of EBUS Strain Elastography in Mediastinal Lymph Node Staging; The E-Predict Multicenter Study Results (Now Available) (ID 1620)

      10:30 - 12:00  |  Presenting Author(s): Roel L.J. Verhoeven

      • Abstract
      • Presentation
      • Slides

      Background

      Systematic assessment of lymph nodal involvement by EBUS-TBNA is indicated for suspected and proven lung cancers. Nodal size and PET characteristics help guide which lymph nodes to sample. Especially smaller lymph nodes remain challenging, since PET is of limited value due to low resolution. Additional ultrasound B-mode features such as lymph node size, margin or node heterogeneity have shown variable predictive outcomes. Ultrasound strain elastography (EBUS-SE) is a promising technique. By monitoring tissue deformation over time using ultrasound imaging, a relative tissue strain can be computed. Lower tissue strain is shown to correlate to malignancy. Using a standardized measurement procedure (RespirationDOI: 10.1159/000494143), we aimed to assess the value of strain elastography for predicting lymph node malignancy in addition to size information.

      Method

      This multicenter prospective international trial [NCT02488928] included patient with suspected or proven lung cancer in five hospitals. Measurements were obtained following to a standardized operating procedure using Pentax-Hitachi EBUS systems. Nodal cytopathology combined with follow up imaging (>6 months) or surgery were used as reference standard. If uncertainty in outcome remained, nodes were excluded in final analysis.

      Result

      EBUS-SE was performed in 416 patients and 525 lymph nodes (June 2016 – July 2018). Final diagnoses showed 272 benign and 253 malignant nodes. Mean lymph node size was 12.3 mm. B-mode size and mean strain correlated to risk of malignancy with AUC of 78% and 76.8% (95% CI 0.73-0.81). Using a clinical work-up setting with 10mm and 8mm size cut-offs for aspiration, short axis size higher than 8 or 10mm resulted in respective sensitivity of 85% and 72%, specificity of 52% and 71%, PPV of 62% and 70% and NPV of 79% and 73%. Addition of strain elastography (mean<90) to EBUS-short-axis size (<10mm) increased overall sensitivity from 72% to 90% and NPV from 73% to 81%. More nodes were found false positive, specificity decreased from 71% to 42% and PPV went from 70% to 59%. Addition of strain (mean<78) to EBUS-size (<8mm) increased sensitivity from 85% to 94% and NPV from 79% to 85%. Specificity decreased from 52% to 32% and PPV from 63% to 55%.

      Conclusion

      EBUS strain elastography is of added value in guiding nodal sampling. Strain and size combined can help identify more malignant nodes, although it will ultimately also lead to more false positive sampling. Strain information may especially be of potential value in nodes of small size, where PET resolution is limited.

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      OA01.06 - Cone Beam CT Imaging for Transbronchial Navigation in Small Peripheral Pulmonary Lesions (Now Available) (ID 1659)

      10:30 - 12:00  |  Author(s): Roel L.J. Verhoeven

      • Abstract
      • Presentation
      • Slides

      Background

      Small peripheral lung lesions have historically been identified and followed according to risk of malignancy. Ideally an accurate minimally invasive diagnostic procedure would become the more common first approach. The bronchoscopic approach herein remains of limited widespread use, and reported pooled diagnostic yields remain at approximately 70% even with the help of additional advanced guiding technology. We evaluated if inter-procedural cone beam CT (CBCT) improves yield in two prospective trials: CBCT assisted navigation bronchoscopy with electromagnetic navigation (EMN) guidance (CONTROL-E, NCT03355586) and without EMN using augmented CBCT fluoroscopy alone (CONTROL-A, NCT03274609).

      Method

      All patients with an indication for a minimal invasive diagnostic procedure of their peripheral pulmonary lesion as found by our multi-disciplinary tumor board between Dec 2017 and Jan 2019 were included. A total of 84 patients (100 nodules) were included and had a navigation bronchoscopy in the hybrid operating room under general anesthesia. Procedural workflow was as follows: CONTROL-A started off with a CBCT scan. The lesion and pathway were then segmented on a separate workstation. Afterwards, both pathway and nodule were projected 2D on live fluoroscopy for navigation and biopsy guidance. CONTROL-E workflow started with electromagnetic navigation (EMN). Upon reaching the planned target or concluding upon unsuccessful navigation, CBCT imaging was performed for verification (or if applicable; consecutive repositioning guidance). In both workflows, r-EBUS mini probe imaging and ROSE were available for additional guidance and verification.

      Result

      The mean lesion size in CONTROL-A (46 patients) was 16.7mm (range 5-43 mm), and 11.5mm (range 4-33 mm) in CONTROL-E (38 patients). A bronchus sign was seen in 62% and 71% of cases, respectively. The CONTROL-E study showed that EMN with r-EBUS had an approximate navigation success rate of 58%. Addition of live 3D-CBCT guidance was performed in all cases, increasing navigation success to 88%. The CONTROL-A study had navigation success of 80% by utilizing only r-EBUS and augmented CBCT-fluoroscopy. However, additional EMN (cross-over) was needed in several cases for navigation guidance, increasing navigation success to 88%. In follow up, both studies showed a diagnostic yield lower than the navigation success: in CONTROL-E 71% and in CONTROL-A, 72% had a biopsy outcome correlating to golden standard follow up.

      Conclusion

      Cone beam CT is of significant added value for transbronchial navigation to small peripheral lung lesions, with or without trans-parenchymal access. Diagnostic yield however remains approximately 71%. Additional refining of navigation and biopsy tools is necessary to further increase intuitiveness and accuracy.

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    P2.05 - Interventional Diagnostic/Pulmonology (ID 168)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.05-02 - Added Value of Transbronchial Cryobiopsy Sampling in Navigation Bronchoscopy for Small Pulmonary Nodules (Now Available) (ID 1442)

      10:15 - 18:15  |  Author(s): Roel L.J. Verhoeven

      • Abstract
      • Slides

      Background

      There is an increased demand for diagnostic procedures for incidental nodules and suspected early stage lung cancer detected on CT. Endobronchial diagnosis using advanced techniques have been able to increase diagnostic yield when compared to previous (semi-) blind transbronchial biopsy. Yet even when state of the art techniques such as intra-operative cone beam CT imaging (cbCT), radial ultrasound miniprobes and / or electromagnetic navigation technology (EMN) are used, in up to 30% of procedures no final histological diagnosis is made even when these small (<2cm) lesions are reached. In this study we aim to investigate the added value of transbronchial cbCT controlled cryobiopsy for peripheral pulmonary nodule evaluation.

      Method

      From a case series of 97 patients who underwent navigation bronchoscopy with histological sampling using either forceps biopsy, cryobiopsy or both were included for analysis. In our routine 6-10 forceps biopsy samples are obtained and when possible followed by a single or repeated cryobiopsy using 3-dimensional cbCT imaging guidance for confirmation for target lesion access during sampling. Retrospective evaluation of specimen quality was performed by a blinded expert pathologist [KG] using a visual analog score for specimen quality classification (range 1-5: very poor to very good). Student T and Pearson chi-square testing were used.

      Result

      The mean nodule size was 14 mm (range 4-43mm). In total 37 cryobiopsy specimens were obtained (from n=33 patients). In 31 samples direct comparison of cryobiopsy and forceps biopsy specimens was available from the same target lesions. The cryobiopsy specimens were larger and showed a better quality than the forceps biopsies, with a mean specimen quality score of 4.2 ± 0,2 compared with 2.9 ± 0,2 (p<0.001). However, the overall sensitivity to prove malignant or benign origin of nodules using cryobiopsy was 43% (16 out of 37) compared to 78% (76 out of 97) for forceps biopsies (p<0.001).

      Conclusion

      Navigation bronchoscopy guided cryobiopsy sampling for small peripheral pulmonary nodules is feasible and renders specimens of significantly better quality with less artefacts and larger size. However, the diagnostic yield is still inferior to forceps biopsy. This can likely be attributed to probe stiffness resulting in mis-alignment in these small nodules and to the fact that the complex navigation procedure allows for obtaining only one single cryobiopsy sample in the vast majority of cases.

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