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Electromagnetic Navigational Bronchoscopy versus CT-guided biopsy

Electromagnetic Navigational Bronchoscopy versus CT-guided biopsy. Multidisciplinary Management of Lung Cancer, June 8, 2013. Douglas J. Minnich, MD Thoracic Surgery University of Alabama at Birmingham Birmingham, AL. Financial Disclosure.

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Electromagnetic Navigational Bronchoscopy versus CT-guided biopsy

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  1. Electromagnetic Navigational Bronchoscopy versus CT-guided biopsy Multidisciplinary Management of Lung Cancer, June 8, 2013 Douglas J. Minnich, MD Thoracic Surgery University of Alabama at Birmingham Birmingham, AL

  2. Financial Disclosure • Physician training for navigation bronchoscopy (Covidien)

  3. Evaluation of Lung Nodule • Solitary pulmonary nodule (SPN) • Estimated annual incidence of 150,000 patients per year in US with new diagnosis of an SPN • Widespread use of CT scans • Radiographic imaging • Chest x-ray • CT scan • PET scan

  4. Biopsy of Lung Nodule • Standard bronchoscopy • Fluoroscopy • Limited yields (19-62%) • Electromagnetic navigational biopsy (ENB) • Transthoracic needle aspiration • Surgical biopsy

  5. Terminology • Company name: Veran Medical Technologies • SPiN Drive • Company name: superDimension, Inc (Covidien) • Operating system: inReach • Latest software version: iLogic • Various names for procedure

  6. Navigation Bronchoscopy Step 1 Step 2 Step 3 Procedure Navigation Biopsy CT Scan DICOM CD Planning Planning File

  7. Procedure Planning

  8. Procedure Planning

  9. Procedure Planning

  10. Procedure Planning

  11. Procedure Planning

  12. Electromagnetic LocalizationReal-Time Location Information Sensors on Patient Account for Inspiration, Expiration and Patient Movement Miniaturized sensor delivers accurate information {x, y, z, roll, pitch, yaw} 166 times/second Location board underneath mattress generates Electromagnetic Field   

  13. Electromagnetic Localization Real-Time Location Information

  14. Procedure: Auto Registration

  15. Navigation Bronchoscopy

  16. Procedure: Navigation to Target

  17. Additional Applications Sampling Lymph Nodes to stage cancer • Diagnosis & Staging in one procedure Injecting dye markers to guide surgical resection • Facilitate minimally invasive approach Placing radiosurgical markers • Stereotactic body radiation therapy (SBRT)

  18. Lymph Node Sampling

  19. Marker Applications Dye Marker ‘Tattooing’ Technique Radiosurgical Marker Technique Dye Marker Placement Indigo carmine dye easily visualized on pleural surface Fiducial Radiosurgical Markers implanted in the Lungs

  20. Dye Marker Placement Methylene blue Indigo carmine dye

  21. Dye Marker Placement

  22. Dye Marker Placement

  23. Dye Marker Placement

  24. Dye Marker Placement

  25. Dye Marker Placement

  26. Dye Marker Placement

  27. Adjunct Technologies • Radial EBUS probe

  28. Adjunct Technologies • Cellvizio (confocal laser endomicroscopy) Normal lung Lung cancer

  29. Literature Review • Schwarz et al. Chest2006;129(4):988–94. • First reported series of ENB in human patients • 13 patients • Diagnostic yield 69% • No procedural complications

  30. Literature Review • Gildea et al. Am J Respir Crit Care Med 2006; 174(9):982–9. • Prospective study from Cleveland Clinic • 60 patients • Diagnostic yield 74% • Pneumothorax 3.5%

  31. Literature Review • Makris et al. Eur Respir J 2007;29(6): 1187–92. • 40 patients • Diagnostic yield 63% • Pneumothorax 5%

  32. Literature Review • Eberhardt et al. Chest 2007;131(6):1800–5. • 89 patients • Diagnostic yield 67% • Pneumothorax 2% • Addition of peripheral EBUS probe • Diagnostic yield 88% • Pneumothorax 6%

  33. Literature Review • Wilson et al. J Bronchol 2007;14: 227–32. • 248 patients • Addition of ROSE • Rapid On-Site Evaluation • Diagnostic yield 70% • Peripheral lung nodules with successful navigation • Diagnostic yield 96% • Pneumothorax 1.2%

  34. UAB Experience

  35. UAB Experience • True negative patients (N=33) • Confirmed pathologic benign following resection (N=17) • Resolution or stability on serial CT scans (N=16) • Mean follow-up 22 months (range 20-25)

  36. UAB Experience Sensitivity - 82% Specificity - 100% Positive predictive value - 100% Negative predictive value – 79%

  37. UAB Experience • Sensitivity of biopsy methods • Needle biopsy – 71.9% • Biopsy forceps – 76.3% • Cytology brushing – 69.0% • Bronchoalveolar lavage – 52.6% • Pneumothorax rate – 0.9% • No significant bleeding complications

  38. UAB Experience • Including true positive and true negative patients • Accuracy – 89% • Presence of bronchus sign is 2x as likely to achieve a diagnostic biopsy • Accuracy without bronchus sign – 66.7% • Accuracy with bronchus sign – 96.7%

  39. UAB Experience • Factors that did not reach statistical significance on univariate analysis • Location (lobe of lung) • Maximum SUV on PET scan • Size of lesion • Mean 2.4 cm

  40. CT – Guided Biopsy (TTNA) • Wide range of diagnostic yields and complications • Skill and interest of radiologist • Diagnostic yields • Complications • Pneumothorax • Bleeding

  41. Conclusions • Strengths • Minimally invasive biopsy of peripheral lung nodules • Low morbidity • Stage mediastinum • Place fiducial markers for radiosurgical treatment • Limitations • Airway orientation to lesion

  42. Conclusions • ENB vs TTNA? • Factors to consider • Resources available • Skill level of bronchoscopist or radiologist • Database • Regular review of results

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