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Wouter Hoefsloot
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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: 1
- Now Available
- Moderators:Marioara Simon, Tim Murgu
- Coordinates: 9/08/2019, 10:30 - 12:00, Melbourne (1991)
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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): Wouter Hoefsloot
- Abstract
- Presentation
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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