Radial Endobronchial Ultrasound and Electromagnetic Navigation Bronchoscopy with Fluoroscopy for the Diagnosis of Peripheral Lung Lesions

Summary

Diagnosing small lung tumors is quite difficult using a bronchoscope alone. Electromagnetic navigation bronchoscopy is used to locate the lesion, similar to the Global Positioning System. Radial endobronchial ultrasound and fluoroscopy confirm the correct location and monitor the sampling.

Abstract

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy for endobronchial lesions, but it falls short when sampling peripheral lesions. Therefore, several modalities have been invented to guide the bronchoscope to the lesion and confirm the location of the tumor before tissue sampling.

Fluoroscopy is used during bronchoscopy to provide a 2D X-ray image of the thorax during the procedure. The bronchoscope and tools will be visible, as well as lesions if larger than 2.0-2.5 cm. Radial endobronchial ultrasound (rEBUS) consists of an ultrasound probe, small enough to be inserted into the working channel of the bronchoscope. The ultrasound probe is used to differentiate between consolidated tissue, such as tumor tissue, and normal air-filled lung parenchyma. Electromagnetic navigation bronchoscopy (ENB) creates a 3D model of the bronchial tree from computed tomography (CT) scans of the patient. Prior to the bronchoscopy, a route from the trachea to the lesion is planned, to create real-time guidance of the bronchoscope to the lesion during the procedure, similar to the Global Positioning System. The aim of this article is to describe a stepwise approach to performing bronchoscopy with rEBUS and fluoroscopy, bronchoscopy with ENB, rEBUS, and fluoroscopy. In the discussion section, the pros and cons of each modality will be discussed.

Introduction

Lung cancer is one of the most common cancer types worldwide and the leading cause of cancer-related deaths¹. Screening for lung cancer with low-dose computed tomography (CT) has therefore been suggested to diagnose patients before symptoms occur². Low stages are often detected as small lung lesions or nodules. From one of the largest screening studies conducted in the Netherlands, we know that these lesions are often located in the outer 2/3 of the lung parenchyma and are thereby defined as peripheral lung cancers^3,4. To determine whether a lesion is malignant, ....

Protocol

The protocol in this article describes standard clinical practice. No permission from the ethical committee was needed. Images in the protocol contain no information which can be used to indentify patients.

1. Radial endobronchial ultrasound

1. Preparing for the procedure
   1. Examine the CT scan to check for bronchus signs and the location of the lesion before the procedure.
   2. Calibrate the ultrasound probe, guide sheath, and biopsy tools of.......

Discussion

This article presents a practical approach for performing rEBUS and ENB with fluoroscopy. The following discussion is the opinion of the authors and is based on practical clinical experience from two centers.

Tips and tricks
rEBUS
Before the procedures the Chest CT sectional walker app can be used to check in which segment the lesion is located¹⁴. However, since the anatomy of patients differs, the lesion may be located in a.......

Materials

Name	Company	Catalog Number	Comments
Bronchoschope	Olympus
Edge Extended working channel	Medtronic
Edge locatable guide	Medtronic
Guide sheath kit	Olympus
OEC fluorostar	GE healthcare		C-arm for fluoroscopy
Probe Driving Unit	Olympus
Radial EBUS probes	Olympus
superDimension	Medtronic		Navigation system