Mobile 3-dimensional (3D) C-arm system-assisted transbronchial biopsy and ablation for ground-glass opacity pulmonary nodules: a case report

Abstract

Identification of pulmonary ground-glass opacity (GGO) lesions during bronchoscopic procedures remains challenging, as GGOs cannot be directly visualized under 2-dimensional (2D) fluoroscopy and are often difficult to detect by radial endobronchial ultrasound. Recently, a mobile 2D/3D C-arm fluoroscopy system was developed that provides both 2D fluoroscopy and mobile 3D imaging to assess and confirm the location of the lesions and ancillary bronchoscopic tools. However, previous studies focused mainly on experience of utilizing mobile 3D C-arm system for transbronchial biopsy of solid pulmonary nodules. Here, we evaluated the feasibility of mobile 3D imaging assisted transbronchial biopsy with and without ablation of two patients with GGO nodules. The first patient underwent biopsy only, and the second patient underwent biopsy in the right upper lobe lung nodule and ablation of a left upper lobe lung nodule in one session. Procedures in both patients were successfully performed, and no significant complications have been observed intra- or post-procedurally. Our case study highlights the potential value of the mobile 3D imaging system in accurate identification of the target lung lesion, confirmation of bronchoscopic tools within the lesion, and assessment of the target lesion and surrounding tissue following bronchoscopic ablation procedure. Furthermore, a "one-stop shop" bronchoscopy workflow combining both biopsy and ablation for one or more lung lesions in one session could be made possible by utilizing a hybrid mobile 2D/3D C-arm system in the bronchoscopy suite.

Keywords: Ground-glass opacity (GGO); bronchoscopy; case report; fluoroscopy; mobile 3D C-arm.

Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/tlcr-21-561). The authors have no conflicts of interest to declare.

2021 Translational Lung Cancer Research. All rights reserved.

Figures

Figure 1

Transbronchial lung biopsy under guidance of mobile 3D imaging and EBUS in patient 1. (A) Pre-procedure mobile 3D imaging of the target (mGGO) confirming the location of the lesion. (B) Intra-procedure mobile 3D imaging confirmation with an EBUS probe within the target lesion. (C) Reaching the target lesion under EBUS, with “blizzard sign” observed. (D) After the insertion of biopsy forceps, transbronchial biopsy was performed under fluoroscopy. (E) In ROSE analysis, a minimal amount of the specimen was smeared on slides, air dried and stained with Diff-Quik. Adenocarcinoma was indicated in black solid arrow, red blood cells was indicated in black dotted arrow and epithelial cells was indicated in red solid arrow (×400). mGGO, mixed ground-glass opacity; 3D, 3-dimensional; EBUS, endobronchial ultrasound; ROSE, rapid on-site evaluation.

Figure 2

Transbronchial lung biopsy of the right lung in patient 2. (A) Chest CT indicated mGGO in the right upper lobe. (B) EBUS image showing a mixed blizzard sign. (C) The EBUS probe reached the lesion under fluoroscopy. (D) Transbronchial brushing under fluoroscopy. (E) Transbronchial biopsy under fluoroscopy. (F) In ROSE analysis, a minimal amount of the specimen was smeared on slides, air dried and stained with Diff-Quik. Adenocarcinoma was indicated in black solid arrow, red blood cells was indicated in black dotted arrow and epithelial cells was indicated in red solid arrow (×400). CT, computed tomography; mGGO, mixed ground-glass opacity; EBUS, endobronchial ultrasound; ROSE, rapid on-site evaluation.

Figure 3

Transbronchial MWA of the left lung in patient 2. (A) ENB showing the locatable wire reaching the target lesion. (B) EBUS image showing a mixed blizzard sign. (C) MWA was performed under fluoroscopy. (D) Mobile 3D imaging showing the ablating tool inside of the lesion. (E) The second mobile 3D scan after ablation showing the lesion covered within the ablation area and a larger opacity, indicating satisfactory placement. (F) Chest CT target lesion before treatment. (G) One-month follow-up chest CT showing successful MWA with an area of thermocoagulation. (H) Nine-month follow-up chest CT showing the interval shrinkage and no contrast enhancement of the mass. CT, computed tomography; MWA, microwave ablation; ENB, electromagnetic navigation bronchoscopy; EBUS, endobronchial ultrasound; 3D, 3-dimensional.