Virtual Bronchoscopy-Guided Transbronchial Biopsy Simulation Using a Head-Mounted Display: A New Style of Flexible Bronchoscopy

Background/need. The increases in reference images and information during bronchoscopy using virtual bronchoscopic navigation (VBN) and fluoroscopy has potentially created the need for support using a head-mounted display (HMD) because bronchoscopists feel difficulty to see displays that are at a distance from them and turn their head and body in various directions. Methodology and device description. The binocular see-through Moverio BT-35E Smart Glasses can be connected via a high-definition multimedia interface and have a 720p high-definition display. We developed a system that converts fluoroscopic (live and reference), VBN, and bronchoscopic image signals through a converter and references them using the Moverio BT-35E. Preliminary results. We performed a virtual bronchoscopy-guided transbronchial biopsy simulation using the system. Four experienced pulmonologists performed a simulated bronchoscopy of 5 cases each with the Moverio BT-35E glasses, using bronchoscopy training model. For all procedures, the bronchoscope was advanced successfully into the target bronchus according to the VBN image. None of the operators reported eye or body fatigue during or after the procedure. Current status. This small-scale simulation study suggests the feasibility of using a HMD during bronchoscopy. For clinical use, it is necessary to evaluate the safety and usefulness of the system in larger clinical trials in the future.

Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Improves the Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Biopsy for Peripheral Pulmonary Lesions

Background: Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of peripheral pulmonary lesions (PPLs), but the diagnostic yield is not adequate. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) can be utilized to assess the location of PPLs and biopsy devices, and has the potential to improve the diagnostic accuracy of bronchoscopic techniques. The purpose of this study was to verify the contribution of CBCT-AF to EBUS-TBB. Methods: Patients who underwent EBUS-TBB for diagnosis of PPLs were enrolled. The navigation success rate and diagnostic yield were used to evaluate the effectiveness of CBCT-AF in EBUS-TBB. Results: In this study, 236 patients who underwent EBUS-TBB for PPL diagnosis were enrolled. One hundred fifteen patients were in CBCT-AF group and 121 were in non-AF group. The navigation success rate was significantly higher in the CBCT-AF group (96.5% vs. 86.8%, p = 0.006). The diagnostic yield was even better in the CBCT-AF group when the target lesion was small in size (68.8% vs. 0%, p = 0.026 for lesions ≤10 mm and 77.5% vs. 46.4%, p = 0.016 for lesions 10–20 mm, respectively). The diagnostic yield of the two study groups became similar when the procedures with a failure of navigation were excluded. The procedure-related complication rate was similar between the two study groups. Conclusion: CBCT-AF is safe, and effectively enhances the navigation success rate, thereby increasing the diagnostic yield of EBUS-TBB for PPLs.

A Pilot Study of Transbronchial Biopsy Using Endobronchial Ultrasonography with a Guide Sheath in the Diagnosis of Peripheral Pulmonary Lesions in Patients with Interstitial Lung Disease

The occurrence of interstitial lung disease (ILD) with peripheral pulmonary lesions (PPLs) is closely linked to the development of lung cancer. Yet, the best diagnostic approach for identifying PPLs in patients with ILD remains elusive. This study retrospectively investigated the application of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS) to the effective and safe diagnosis of PPLs when compared with conventional TBB. The study sample included a consecutive series of 19 patients with ILD who underwent conventional TBB or TBB using EBUS-GS at Tosei General Hospital between 1 April 2013 and 31 October 2015. The two techniques were compared based on diagnostic yield and associated complications. The diagnostic yield of EBUS-GS TBB was significantly higher than that of conventional TBB (p = 0.009), especially for small lesions (≤20 mm), lesions located in the lower lobes, lesions with a positive bronchus sign, and lesions visible by chest radiography (p = 0.010, p = 0.022, p = 0.006, and p = 0.002, respectively). There were no significant differences in complication rates. Therefore, EBUS-GS is an effective alternative for the diagnosis of PPLs in patients with ILD, without additional complications.

Endobronchial Ultrasonography with a Guide Sheath Transbronchial Biopsy for Diagnosing Peripheral Pulmonary Lesions within or near Fibrotic Lesions in Patients with Interstitial Lung Disease

In patients with interstitial lung disease (ILD), the most frequent locations of lung cancer are within or near fibrotic lesions. However, the diagnostic yield for peripheral pulmonary lesions (PPLs) within or near fibrotic lesions using endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) may be unsatisfactory compared to that for PPLs distant from fibrotic lesions because of the difficulty in reaching the lesions. Our objectives were to evaluate the yield for PPLs using EBUS-GS TBB according to the proximity of PPLs to fibrotic lesions and to determine factors affecting the yield for PPLs. We retrospectively investigated 323 consecutive lesions using EBUS-GS TBB between 1 November 2014 and 31 December 2016. We identified PPLs with ILD in such lesions. PPLs with ILD were divided into PPLs within or near fibrotic lesions which met the criterion of PPLs, and of fibrotic lesions overlapping each other (PPLs-FL) and those distant from fibrotic lesions, which met the criterion of PPLs and the area of fibrotic lesion not overlapping each other (PPLs-NFL). Of the 323 lesions, 55 were included (31 PPLs-FL and 24 PPLs-NFL). The diagnostic yield for PPLs-FL was significantly lower than for PPLs-NFL (45.2% vs. 83.3%, p = 0.004). Multivariate analysis revealed that PPLs-NFL (odds ratio (OR) = 7.509) and a probe position within the lesion (OR = 4.172) were significant factors affecting diagnostic yield. Lesion’s positional relation to fibrotic lesions and the probe position were important factors affecting the successful diagnosis via EBUS-GS TBB in these patients.

Removal of hematoma due to massive hemoptysis after transbronchial biopsy: a case report

Background Massive hemoptysis is a life-threatening complication after transbronchial biopsy (TBB). Reports on massive hemoptysis occurring several days after TBB are scarce. Case presentation A 62-year-old man presented with massive hemoptysis and was admitted to hospital as an emergency on the eighth day after TBB. On the 12th day after TBB, computed tomography showed complete atelectasis of the right middle and lower lobes. The patient underwent emergent right upper lobectomy. The right upper lobe bronchus was separated with a scalpel, the hematoma was pulled out with forceps, and the bronchus subsequently sutured shut. The patient was discharged from the hospital uneventfully. Conclusions We experienced a case of massive hemoptysis on the eighth day after TBB, which required emergency surgery due to persistent bleeding into the airway and airway obstruction during follow-up. Postoperative pneumonia and atelectasis could be prevented by manual removal of the residual hematoma.

Yield of tumor samples with a large guide-sheath in endobronchial ultrasound transbronchial biopsy for non-small cell lung cancer: A prospective study

Background Adequate tumor tissue is required to make the best treatment choice for non-small cell lung cancer (NSCLC). Transbronchial biopsy (TBB) by endobronchial ultrasonography with a guide sheath (EBUS-GS) is useful to diagnose peripheral lung lesions. The data of tumor cell numbers obtained by two different sizes of GSs is limited. We conducted this study to investigate the utility of a large GS kit to obtain many tumor cells in patients with NSCLC. Methods Patients with a peripheral lung lesion and suspected of NSCLC were prospectively enrolled. They underwent TBB with a 5.9-mm diameter bronchoscope with a large GS. When the lesion was invisible in EBUS, we changed to a thinner bronchoscope and TBB was performed with a small GS. We compared the tumor cell number prospectively obtained with a large GS (prospective large GS group) and those previously obtained with a small GS (small GS cohort). The primary endpoint was the tumor cell number per sample, and we assessed characteristics of lesions that could be obtained by TBB with large GS. Results Biopsy with large GS was performed in 55 of 87 patients (63.2%), and 37 were diagnosed with NSCLC based on histological samples. The number of tumor cells per sample was not different between two groups (658±553 vs. 532±526, estimated difference between two groups with 95% confidence interval (CI); 125 (-125–376), p = 0.32). The sample size of the large GS group was significantly larger than that of the small GS cohort (1.75 mm2 vs. 0.83 mm2, estimated difference with 95% CI; 0.92 (0.60–1.23) mm2, p = 0.00000019). The lesion involving a third or less bronchus generation was predictive factors using large GS. Conclusions The sample size obtained with large GS was significantly larger compared to that obtained with small GS, but there was no significant difference in tumor cell number. The 5.9-mm diameter bronchoscope with large GS can be used for lesions involving a third or less bronchus generation.