A protocol was approved by the local Institutional Review Board (IRB). Participants provide signed informed consent prior to completing the protocol.
1.&#160;Pre-procedure
<ol>
	<li>Ensure that the candidates for the electromagnetic navigational transthoracic needle aspiration have a peripheral pulmonary nodule. Determine the pulmonary nodule use of imagining studies. 
	NOTE: The most common one and needed for this protocol is by evaluating previously obtained chest CT.</li>
	<li>On the day of the procedure attach&#160;the electronic reference point&#160;pads to the contralateral hemithorax of the target lesion to minimize pad overlap with the TTNA biopsy entrance point. Obtain a baseline inspiratory and expiratory non-contrast chest tomography with 0.5 mm intervals and 0.67 - 0.75 mm thickness.</li>
	<li>Transfer the digital imaging and communication in medicine (DICOM) data from the CT scanner to the planning software. If DICOM is unavailable, a compact disk (CD) copy of the CT can be directly loaded onto the system for planning. Digitally select the target lesion and reconstruct a three-dimensional virtual airway map.</li>
	<li>Transport the patient by stretcher from the CT scanner to the bronchoscopy suite with electronic reference points in place.</li>
	<li>Evaluate the patient for anesthesia, establish I.V. access and attach standard anesthetic monitoring.</li>
	</ol>
 class="jove_title"2. Procedure (Bronchoscopic Phase)
<ol>
	<li>Transfer the patient to the bronchoscopy suite. Administer deep sedation&#160;anesthesia using a propofol infusion (100 - 200 mcg/kg/min). An airway is established with laryngeal mask airway (LMA) or endotracheal tracheal tube (ETT). 
	NOTE: Anesthesia can only be administered by a certified provider.</li>
	<li>Perform a white light bronchoscopy (WLB) inspection in the standard fashion examining the tracheobronchial tree to the segmental level.</li>
	<li>Perform an EBUS-TBNA following the International Association for the Study of Lung Cancer (IASLC) lymph node map for lung cancer staging. If available, fine needle aspiration (FNA) specimens are cytological analyzed on-site. If not, the sample is place in formalin for later evaluation.</li>
	<li>Use the WLB bronchoscope with the EMN bronchoscopy program phase following the previously computer recognized or manually planed endobronchial pathway to the target lesion with an instrument of choice at the proceduralists discretion (Cytology brush, jaw biopsy forces, FNA Needle).</li>
	<li>Advance the R-EBUS through the working channel and attempt to confirm the location of the lesion.</li>
	<li>Once in the target, sample the lesion with the operator selected trackable instrument used to navigate. (Cytology brush, jaw biopsy forces, FNA Needle).</li>
	<li>If the target is unable to be verified by radial EBUS or the airway anatomy prohibits endobronchial navigation remove the bronchoscope and prepare the patient for a transthoracic approach. &#160;If the lesion cannot be diagnosed bronchoscopically prepare the patient for a transthoracic approach.</li>
	</ol>
3. Procedure (Electromagnetic Transthoracic Needle Aspiration)
<ol>
	<li>Allocate all supplies needed for the TTNA. (see Material&#160;Table)</li>
	<li>Position the patient supine in a similar fashion used for chest CT scan imaging acquisition.</li>
	<li>Using a test electromagnetic navigational needle select the entrance point to the chest cavity and mark it on the skin surface. Entrance point should be superior to the surface of the nearest rib and avoid osseous structures and any vascular structure.</li>
	<li>Prepare the skin with the 2% chlorhexidine solution, drape the field using sterile technique and anesthetize locally (subcutaneous infiltration of about 1 to 2 cc of 1% lidocaine).</li>
	<li>Place the sterile electromagnetic navigational needle on top of the entrance point and select the angle to the target based on observation of the transverse and coronal views seen on the electromagnetic system screens. (Crosshair marks in at least two different planes.)</li>
	<li>Stabilize&#160;the needle and firmly advanced through the chest wall into the target lesion.</li>
	<li>Remove the guidance needle stylet from the needle and take care to avoid needle movement. At this point extreme care should be use to prevent inadvertent needle displacement. Cover the needle hub with your finger.&#160;Insert the 20 G FNA needle through the 19 G needle. Sample the lesion and provide the specimen for ROSE.&#160;</li>
	<li>Program the automatic needle biopsy to the desired distance or throw based on the size of the lesion, and then insert it through the 19 G needle. Stabilize both needle and biopsy gun, trigger the needle biopsy gun mechanism to perform the biopsy and remove from the inside of the electromagnetic navigational guide needle making sure it remains in appropriate position.</li>
	<li>Gently advance the guidance probe back into the lumen of the percutaneous needle and keep it stable.</li>
	<li>While the needle is continuously stabilized, the assistant uses the scalpel blade to gently remove the specimen from the inner cannula of the core biopsy needle and place it on the 1/2 x 1/2 inch previously cut non adherent pad. Immerse the pad in a formalin solution.</li>
	<li>Reconfirm appropriate placement of the needle within the lesion and then repeat the operation 4 to 5 times making sure the core needle is rotated clockwise or counterclockwise to sample different areas.</li>
	<li>Once satisfied with the specimens remove the needle, apply pressure and place a small bandage over the puncture site.</li>
	</ol>
4. Post Procedure
<ol>
	<li>If available, perform&#160;bedside ultrasonography to assess for the presence of lung sliding (absence of pneumothorax) or use any other imaging modality (fluoroscopy,etc) .</li>
	<li>Transfer the patient to the recovery area and observe&#160;under standard ambulatory surgical unit protocols until fully awake.</li>
	<li>Obtain a chest radiograph to rule out complications.</li>
	<li>Discharge patient home after education is provided regarding the potential post procedure complications including bleeding and pneumothorax.</li>
	</ol>

<ol>
	<li>Govert, J. A., Dodd, L. G., Kussin, P. S., Samuelson, W. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+comparison+of+fiberoptic+transbronchial+needle+aspiration+and+bronchial+biopsy+for+bronchoscopically+visible+lung+carcinoma.">A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma.</a> Cancer. 87, 129-134 (1999).</li><li>Gasparini, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bronchoscopic+biopsy+techniques+in+the+diagnosis+and+staging+of+lung+cancer.">Bronchoscopic biopsy techniques in the diagnosis and staging of lung cancer.</a> Monaldi Arch Chest Dis. 52, 392-398 (1997).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=United+States+cancer+statistics:+1999-2010+incidence+and+mortality+web-based+report.">United States cancer statistics: 1999-2010 incidence and mortality web-based report.</a> US Department of Health and Human Services Centers for Disease Control and Prevention and National Cancer Institute. , (2014).</li><li>Silvestri, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methods+for+staging+non-small+cell+lung+cancer:+Diagnosis+and+management+of+lung+cancer,+3rd+ed:+American+College+of+Chest+Physicians+evidence-based+clinical+practice+guidelines.">Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.</a> Chest. 143, e211S-e250S (2013).</li><li>Steinfort, D. P., Khor, Y. H., Manser, R. L., Irving, L. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+probe+endobronchial+ultrasound+for+the+diagnosis+of+peripheral+lung+cancer:+systematic+review+and+meta-analysis.">Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis.</a> The European respiratory journal. 37, 902-910 (2011).</li><li>Gex, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+yield+and+safety+of+electromagnetic+navigation+bronchoscopy+for+lung+nodules:+a+systematic+review+and+meta-analysis.">Diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules: a systematic review and meta-analysis.</a> Respiration; international review of thoracic diseases. 87, 165-176 (2014).</li><li>Wang Memoli, J. S., Nietert, P. J., Silvestri, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+guided+bronchoscopy+for+the+evaluation+of+the+pulmonary+nodule.">Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule.</a> Chest. 142, 385-393 (2012).</li><li>Lee, K. A., Raval, A. A., Amir, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cost-effectiveness+of+endobronchial+percutaneous+biopsy+compared+with+transthoracic+biopsy+for+diagnosis+of+peripheral+lung+lesions.">Cost-effectiveness of endobronchial percutaneous biopsy compared with transthoracic biopsy for diagnosis of peripheral lung lesions.</a> Lung Cancer Management. 3 (2), 135-148 (2014).</li><li>Rivera, M. P., Mehta, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+College+of+Chest,+P.+Initial+diagnosis+of+lung+cancer:+ACCP+evidence-based+clinical+practice+guidelines+(2nd+edition).">American College of Chest, P. Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).</a> Chest. 132, 131S-148S (2007).</li><li>Wiener, R. S., Schwartz, L. M., Woloshin, S., Welch, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Population-based+risk+for+complications+after+transthoracic+needle+lung+biopsy+of+a+pulmonary+nodule:+an+analysis+of+discharge+records.">Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records.</a> Annals of internal medicine. 155, 137-144 (2011).</li></ol>

The authors received research funding that was provided by Veran Medical Technologies Inc., which produces the EM and TTNA instruments used in this publication.

Electromagnetic guidance facilitates the percutaneous transthoracic biopsy technique. It is critical during the procedure to verify adequate equipment calibration. During needle insertion maintaining a steady angle and keeping visual alignment using at least two different planes is essential to effectively reach the target lesion.
Needle insertion depth can be modified between biopsies to maximize the cover area. Preferably,&#160;the procedure could be assisted by a second operator, especially at the time of biopsy gun operation, but a single operator procedure is feasible.
Familiarization with the instruments and technique takes approximately 2 to 3 needle insertions. If available training on phantom models or cadaveric models under direct supervision of an experienced operator is advisable. Electromagnetic navigational transthoracic needle aspiration (E-TTNA) is a novel technology that supplements the current armamentarium for the diagnosis of peripheral pulmonary nodules. Potential limitations of the procedure are inherent to the electromagnetic navigational technology, like CT to body divergence and related to the dynamic nature of the respiratory system. We recommend anticipation for the management of complications like pneumothorax and bleeding should be taken during any percutaneous procedure.
In this article we describe how the E-TTNA is performed by interventional pulmonologist and the incorporation of the technique to the current available bronchoscopic methods for the evaluation of lung nodules.
E-TTNA potentially can reduce the need for other image guided percutaneous transthoracic procedures providing full integration of bronchoscopic and non-bronchoscopic techniques in one single procedure potentially increasing diagnostic yield, improving safety and decreasing the overall number of procedures. Further studies are needed to determine clinical utility of this modern biopsy technique.

A solitary pulmonary nodule (SPN) is a frequent clinical scenario that is increasing due to the number of radiographic chest studies and the implementation of lung cancer screening programs. A lung nodule by definition is less than 3 cm in diameter and &#160;one that typically lies beyond the bronchoscopically visualized segmental bronchi. A lesion larger than 3 cm is considered a lung mass. The etiologies of the majority of lung nodules are benign conditions (infections, inflammatory, vascular) and in a smaller percentage are caused by lung cancer and other malignancies. Evaluation of a SPN starts with assessment of risk factors, radiographic characteristics, size, growth, location, surgical risk, etc. Risk stratification helps to select the most appropriate individual management, which ranges from radiologic surveillance to primary surgical resection. Diagnostic modalities include bronchoscopic techniques: ( bronchoalveolar lavage (BAL), cytology brush, transbronchial biopsy (TBBx), transbronchial needle aspiration (TBNA), radial probe endobronchial ultrasound (R-EBUS), electromagnetic navigation (EMN), ultrathin bronchoscopy, virtual bronchoscopy navigation) and non-bronchoscopic: image guided transthoracic needle biopsy and surgical resection.
The bronchoscopic yield using simple conventional techniques for lesions less &#60;3 cm ranges from 14 &#8211; 50%. 1,2 Lung cancer remains the leading cause of cancer deaths. It represents 14% of all invasive cancers diagnosed each year and 28% of all cancer deaths in the United States.3 Prognosis and treatment management are determined by the stage. The staging of non-small cell lung cancer (NSCLC) is defined by the TNM system. Determination of the N or nodal status requires strict assessment of the mediastinal and hilar lymph nodes.
Endobronchial ultrasound (EBUS) is a minimally invasive bronchoscopic technique that uses ultrasound to identify structures contiguous to the airways facilitating transbronchial needle aspiration (TBNA). For lung cancer staging a recent meta-analysis reported a median sensitivity of 89% with values ranging from 46% to 97% and a median negative predictive value PV of 91% for EBUS-TBNA. 4 Radial EBUS is another bronchoscopic tool that can be used to localize parenchymal lung lesions. It is a 1.4 mm diameter instrument with a 20-MHz ultrasound probe at the tip that generates 360 degree images with a penetration of 5 cm. Recently reported data of this technique showed a sensitivity of identifying neoplasia of 73% (95% CI, 0.70 - 0.76) for nodules of any size and 71% (95% CI, 0.66 - 0.75) for lesions smaller than 2.5 cm 5 .
Electromagnetic Navigational Bronchoscopy (ENB) is a technology that creates a magnetic field around the patient allowing determination of the spatial location of a sensor device within the magnetic field. This information is superimposed on previously obtained computed tomography (CT) images, which permit a display of the sensor location in relationship to the anatomy. A virtual bronchoscopy reconstruction of the patient&#39;s airways facilitates navigation to the target lesion. Once in the target, samples are taken directly using one of the two available technologies; trackable bronchoscopic instruments or through an extended working channel. Overall diagnostic accuracy was 73.9% (95% CI 68.0%&#160;- 79.2%) and negative predictive value 52.1% (95% CI 43.5% - 60.6%) and when using at least one of the other technologies (virtual bronchoscopy, ENB, Radial-EBUS, guide sheath, ultrathin bronchoscope) the diagnostic yield was 70.0% with a 95% CI of 67.1% to 72.9% 67 One of the commercially available systems has the added feature to complement&#160;bronchoscopic navigation with the ability to convert from a bronchoscopic approach to a transthoracic needle approach in cases where the lesion is unable to be accessed bronchoscopically. This system uses an electromagnetic navigation guided 19 G tracking needle that allows for the sampling of core lung biopsies using a 20 G automatic biopsy device.
Transthoracic needle aspiration (TTNA) is a non bronchoscopic diagnostic approach to lung nodules and masses. TTNA of a peripheral lung lesion can be performed under ultrasonography, fluoroscopy, CT scan or electromagnetic guidance. In an updated meta-analysis by Rivera et al&#160;the pooled sensitivity of TTNA for the diagnosis of peripheral bronchogenic carcinoma was 0.90 (95% CI,&#160;0.88 to 0.91).8 In a study by Wiener RS that included 15,865 patients with a reported risk of pneumothorax after TTNA of 15% (95% CI, 14% - 16%) with 7% (95% CI, 6% - 7.2%) requiring management with a chest tube. 9 Clinical trials investigating the use of E-TTNA are currently underway.
CASE PRESENTATION
An 83 year old female former smoker with oxygen dependent chronic obstructive pulmonary disease was incidentally found with a PET fluorodeoxyglucose avid 1.6 x 1.3 cm spiculated right upper lobe (RUL) nodule (Figure 1). Although her probability for malignancy was high, the patient refused surgical interventions and opted for a diagnostic procedure before considering other therapies. The typical scenario that may prompt consideration for an evaluation for biopsy would be a case of intermediate probability for malignancy or with a high probability for malignancy with a contraindication for surgical resection.

<table><tbody><tr><td>20 G x 15 cm Programmable automatic biopsy needle</td><td>SuperCore Argon Medical devices</td><td>701120150</td><td></td></tr><tr><td>Non Adherent Pads</td><td>Telfa&amp;nbsp;</td><td></td><td></td></tr><tr><td>Sterile scissor</td><td></td><td></td><td></td></tr><tr><td>2% chlorhexidine gluconate pad</td><td></td><td></td><td></td></tr><tr><td>Surgical Blade #11</td><td></td><td></td><td></td></tr><tr><td>Sterile surgical drape</td><td></td><td></td><td></td></tr><tr><td>1% lidocaine</td><td></td><td></td><td></td></tr><tr><td>Sterile gowns</td><td></td><td></td><td></td></tr><tr><td>Sterile gloves</td><td></td><td></td><td></td></tr><tr><td>Mask</td><td></td><td></td><td></td></tr><tr><td>Scrub hair cap</td><td></td><td></td><td></td></tr><tr><td>Electronic reference points&amp;nbsp;</td><td>vPAD2 (Veran Medical Technologies)</td><td>INS-0049</td><td></td></tr><tr><td>Planning software&amp;nbsp;</td><td>SPiNDrive&amp;nbsp;2.0 (Veran Medical Technologies)&amp;nbsp;</td><td></td><td></td></tr><tr><td>Eelectromagnetic navigation platform</td><td>SPiNView (Veran Medical Technologies)</td><td></td><td></td></tr><tr><td>19 G x 105 mm Electromagnetic navigational needle</td><td>SPiNPerc&amp;nbsp; Veran Medical Technologies</td><td>INS-0029</td><td></td></tr><tr><td>Standard diagnostic Fiberoptic Bronchoscope</td><td></td><td></td><td></td></tr><tr><td>EBUS Bronchoscope</td><td></td><td></td><td></td></tr><tr><td>Radial EBUS probe UM-S20-17S</td><td>Olympus</td><td></td><td></td></tr><tr><td>Formaldehyde-based fixative solution.</td><td></td><td></td><td></td></tr><tr><td>Ethanol based fixative</td><td></td><td></td><td></td></tr></tbody></table>

use of electromagnetic navigational transthoracic needle aspiration (e-ttna) for sampling of lung nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

All tissue samples obtained by EBUS-TBNA and E-TTNA are processed by the central pathology laboratory for further analysis. Pathological evaluation of the samples includes cytological and histological assessment. Rapid on-site evaluation (ROSE) uses a modified Romanowsky stain that allows adequacy evaluation and a cytomorphological diagnostic assessment of the pathological specimens. A preliminary intra procedure assessment using ROSE of the EBUS-TBNA biopsies taken from the mediastinal lymph node stations 4L,4R and 7 was unrevealing of obvious neoplasm. The navigational bronchoscopic phase, supported with radial EBUS, failed to localize the right upper lobe lesion due to anatomical limitations. The procedure was rapidly converted to E-TTNA. E-TTNA was successfully performed and the obtained tissue was sufficient for further pathological and genetic analysis. The final pathology of the E-TTNA core sample biopsies was diagnostic and consistent with adenocarcinoma. No immediate complications were noted.
<img alt="Figure 1" src="/files/ftp_upload/52723/52723fig1.jpg" /> 
Figure 1. Chest Computed Tomography (Panel A) and Positron Emission Tomography (PET) (Panel B). Right upper lobe nodule with a PET negative mediastinum. Scale in cm.

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Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently ...

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22.2K Views.  Johns Hopkins University. We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules. 

Video: Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

Transthoracic Echocardiography in Mice

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene expression. Transgenic and gene targeting methods can be used to generate mice with altered cardiac size and function,1-3 and as a result, in vivo techniques are needed to evaluate their cardiac phenotype. Transthoracic echocardiography, pulse wave Doppler (PWD), and tissue Doppler imaging (TDI) can be used to provide dimensional measurements of the mouse heart and to quantify the degree of cardiac systolic and diastolic performance. Two-dimensional imaging is used to detect abnormal anatomy or movements of the left ventricle, whereas M-mode echo is used for quantification of cardiac dimensions and contractility.4,5 In addition, PWD is used to quantify localized velocity of turbulent flow,6 whereas TDI is used to measure the velocity of myocardial motion.7 Thus, transthoracic echocardiography offers a comprehensive method for the noninvasive evaluation of cardiac function in mice.

Transthoracic echocardiography offers a noninvasive method for the evaluation of cardiac function in mice. A combination of ultrasound and Doppler imaging modalities can be used to obtain dimensional measurements of the heart and intracardiac blood flow, which together provide an assessment of cardiac systolic and diastolic performance.

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene ...

Simulation-Based Training of EBUS-TBNA

Systematic Endobronchial Ultrasound - The Six Landmarks Approach

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial to obtain valid biopsies from suspected tumors and mediastinal lymph nodes and accurate identification of the mediastinal lymph nodes regarding the Tumor-Node-Metastasis (TNM)-classification. Flexible bronchoscopy combined with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is essential in the workup and diagnosis of patients suspected of lung cancer. EBUS-TBNA from mediastinal lymph nodes is a technically difficult procedure and has been identified as one of the most important procedures that should be integrated into a simulation-based training program for invasive pulmonologists. More specific guidelines that govern training in EBUS-TBNA are needed to meet this demand. We hereby propose a systematic, stepwise approach with specific attention to six landmarks that support the endoscopist when navigating through the bronchial maze. The stepwise approach relying on the six landmarks is used in the EBUS-certified training program offered by the European Respiratory Society (ERS).

Author Spotlight: Demonstrating Systematic Endobronchial Ultrasound to New Endoscopists 

Endobronchial ultrasound-guided sampling using transbronchial needle aspiration plays a key role in staging and diagnosing lung cancer. We propose a systematic stepwise approach dividing the procedure into six landmarks that should be taught to new operators.

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial ...

Cancer Research

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Detection of Extravascular Trypanosoma Parasites by Fine Needle Aspiration

Fine Needle Aspiration (FNA) is a routine diagnostic procedure essential to both medical and veterinary practices. It consists of the percutaneous aspiration of cells and/or microorganisms from palpable masses, organs or effusions (fluid accumulation in a body cavity) using a thin needle similar to the regular needle used for the venous puncture. The material collected by FNA is in general highly cellular, and the retrieved aspirate is then smeared, air dried, wet-fixed, stained and observed under a microscope. In the clinical context, FNA is an important diagnostic tool that serves as a guide to the appropriate therapeutic management. Because it is simple, fast, minimally invasive and requires limited investment in the laboratory and human resources, it is extensively used by veterinary practitioners, mostly in domestic, but also in farm animals. In studies using animal models, FNA has the advantage that it can be performed repeatedly in the same animal, enabling longitudinal studies through the collection of cells from tumors and organs/tissues over the course of the disease. In addition to routine microscopy, retrieved material can also be used for immunocytochemistry, electron microscopy, biochemical analysis, flow cytometry, molecular biology or in vitro assays. FNA has been used to identify the protozoan parasite Trypanosoma brucei in the gonads of infected mice, opening the possibility for a future diagnosis in cattle.

Detection of Extravascular Trypanosoma Parasites by Fine Needle Aspiration

Fine Needle Aspiration is a technique, whereby cells are obtained from a lesion or organ using a thin needle. Aspirated material is smeared, stained and examined under a microscope for diagnosis or used for molecular biology, cytometry or in vitro analysis. It is cheap, simple, quick and causes minimal trauma.

Fine Needle Aspiration (FNA) is a routine diagnostic procedure essential to both medical and veterinary practices. It consists of the percutaneous ...

Immunology and Infection

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Diseases and Peripheral Pulmonary Lesions - A Stepwise Approach

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted thoracic surgery lung biopsy (SLB) for diagnosing interstitial lung diseases (ILDs). The indication for TBLC has primarily been to sub-classify a specific ILD subtype when this cannot be achieved on the basis of a preceding multidisciplinary team discussion. Although SLB is considered the gold standard for establishing a histological diagnosis, TBLC has been gradually suggested as the first-choice histological diagnostic modality in patients with unclassified ILDs due to a comparable diagnostic yield with SLB, but superior to SLB in terms of complications, including mortality. During recent years, radial endobronchial ultrasound (R-EBUS) and electromagnetic navigation bronchoscopy (ENB)-guided TBLC for peripheral pulmonary lesions have also been described as safe procedures, which may improve the diagnostic yield compared to forceps biopsies. Still, the diagnostic properties of TBLC rely on the quality of the procedure&#39;s performance. This article aims to describe the stepwise approach to conducting TBLC with a flexible bronchoscope for the different indications mentioned, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) for diagnosing interstitial lung disease and peripheral pulmonary lesions is a high-yield diagnostic and safe procedure. We describe a stepwise approach to conduct TBLC for the different indications mentioned with a flexible bronchoscope, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted ...

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

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.

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.

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy ...

A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. When selecting the most suitable invasive procedure to establish a diagnosis in these cases, a delicate balance must be struck between achieving a high diagnostic yield, providing staging information, minimizing potential complications, enhancing the patient experience, and controlling costs. The integration of thoracic ultrasound as a routine clinical tool in respiratory medicine has led to increased awareness and utilization of ultrasound-guided invasive techniques in chest procedures, including transthoracic biopsies. By following a systematic and stepwise approach, transthoracic ultrasound-guided lung biopsy emerges as a safe, cost-effective procedure with a remarkable diagnostic accuracy. These attributes collectively position it as an ideal invasive technique when technically feasible. Consequently, in patients presenting subpleural lung lesions suspected of malignancy, transthoracic ultrasound-guided lung biopsy has become a standard procedure in the realm of modern invasive pulmonology.

Transthoracic ultrasound-guided lung biopsy represents a safe, cost-effective, and efficient approach for patients presenting with subpleural lung lesions suspected of malignancy. Employing a systematic, step-by-step process is crucial to achieve optimal patient selection, minimize complication risks, and maximize diagnostic accuracy.

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. ...

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...

Monitoring Pulmonary Nodule Progression Using Micro-Computed Tomography and Blood Sampling in a Mouse Model

Micro-computed tomography (micro-CT) is a real-time, intuitive, sensitive, and minimally invasive technique for monitoring changes from pulmonary nodules (PN) to lung cancer (LC). The integration of submandibular vein blood sampling enables rapid, stable, and straightforward detection of imaging and key target alterations during the progression of PN to LC. In this study, we administered a dosage of 100 mg/kg of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in A/J mice to develop a lung adenocarcinoma model. Disease progression in the experimental animals was then monitored through submandibular vein blood sampling and micro-CT assay. Experimental results showed the presence of nodular foci in the lungs of some animals by the 10th week, with the development of lung adenocarcinoma images becoming evident by the 21st week. In conclusion, micro-CT can effectively observe pathological changes in the lungs of mice and, when combined with submandibular vein blood sampling, can dynamically monitor changes in blood, protein, and targets. This method provides a highly specific, simple, and sensitive approach for drug screening, pharmacokinetic testing, toxicological experiments, and safety studies.

This protocol describes an efficient, simple, and minimally invasive method for studying pulmonary nodules. Submaxillary vein blood collection and micro-CT imaging are used as investigative techniques.

Micro-computed tomography (micro-CT) is a real-time, intuitive, sensitive, and minimally invasive technique for monitoring changes from pulmonary nodules ...

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

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Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Diseases and Peripheral Pulmonary Lesions - A Stepwise Approach

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

A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Monitoring Pulmonary Nodule Progression Using Micro-Computed Tomography and Blood Sampling in a Mouse Model