February 28, 2023
Rise of Lung Nodule Biopsy
- Over 415,581 chest CTs were obtained from 2006 to 2012
- Lung nodule identification increased from 24% to 41% of all scans1
- There is increase need for accurate biopsy of suspicious lung nodules
- 1876
Gustav Killian removed pork bone from farmer's right bronchus using laryngoscope (directe bronkoscopie).
First direct bronchoscopy
- 1904
Chevalier Jackson introduced first illuminated rigid bronchoscope. He became renowned for extracting aspirated or swallowed foreign objects.
Development of rigid bronchoscope
- 1962
Shigeto Ikeda developed first fiberoptic, flexible bronchoscope.
Development of flexible bronchoscope
- 1972
Howard Anderson performed first transbronchial lung biopsy.
First transbronchial biopsy
- 1992
Heinrich Becker introduced radial probe endobronchial ultrasound for endobronchial sampling.
Radial probe ultrasound
- 2003
Kazuhiro Yasufuku first demonstrated the high diagnostic yield of the convex probe EBUS.
Convex probe ultrasound
- 2006
First published human study by Schwarz Yehuda.
Electromagnetic Navigational Bronchoscopy
Brief History of Bronchoscopy
Standard Biopsy Techniques Are Limited
- Large size of scope limits access to peripheral nodules1
- Flexible bronchoscopy has low sensitivity for malignancy
- Diagnostic yield 34% for lesions < 2 cm and 63% for > 2 cm2
- Electromagnetic navigation bronchoscopy (ENB) uses 3D mapped pathway to lung nodule
- Recent study shows ENB with higher sensitivity around 70%3
- CT guided lung biopsy still have highest sensitivity around 90%2
- March 2018
Monarch™ received FDA approval.
Monarch™ Robotics
- December 2019
The Transbronchial Biopsy Assisted by Robot Guidance in the Evaluation of Tumors of the Lung study (TARGET) was started. Single arm, multi-center, prospective, observational study. Projected end date December 2023.
- August 2022
Initial study result found 97.5% navigational success.
- February 2019
The Ion™ Endoluminal System received its FDA approval.
Ion™ Robotics
- March 2019
Prospective, Multi-Center Evaluation of the Clinical Utility (PRECIsE) trial started. Estimated end date January 2023.
- October 2021
Initial abstract published showing diagnostic yield (83%, 95% CI: 71.6-90.7). Yield for nodules ≤2cm was 82% and for nodules >2cm was 85%; p=1.0.
Robotics Bronchoscopy
Robotic-Assisted Navigation Bronchoscopy as a Paradigm Shift in Peripheral Lung Access
- Published in Lung, September 18, 2020
- Single center, prospective, observational study
- Patients enrolled from Mountain View, California Interventional Pulmonology (IP) clinic of the Palo Alto Medical Foundation (PAMF)
- 52 patients enrolled from September 2019 to June 2020
- Aim was to evaluate diagnostic yield of robotic-assisted bronchoscopy with cone beam CT
- Ion Endoluminal Robotic Bronchoscopy System was used
Our Equipment
All patients presented to clinic for evaluation of indeterminant peripheral pulmonary nodules werwe selected. One patient declined and choose ENB. Patients who were not candidates for general anesthesia were excluded.
Patient selection
Thin cuts between 1-1.5 mm.
Preprocedural CT
All patients underwent anesthesia with tidal volume of 8 cc/kg ideal body weight, positive end expiratory pressure of 10 cm H2O, neuromuscular blockade.
General anesthesia
Robotic catheter navigated to target lesion. Biopsy needle was inserted. Initial CBCT performed. Directional adjustments made. Repeat CBCT verified location. Biopsy performed. Final CBCT used to rule out pneumothorax.
Biopsy steps
Strengths
- First published prospective trial of robotic assisted bronchoscopic biopsy
Weaknesses
- Single center, observational study
- Small sample size
- Unclear contribution from cone beam CT to diagnostic yield
- Pritchett et al. found yield of CBCT with ENB to be 83.7%1