Cone Beam Computertomography (CBCT) in Interventional Chest Medicine - High Feasibility for Endobronchial Realtime Navigation

Wolfgang Hohenforst-Schmidt, Paul Zarogoulidis, Thomas Vogl, J Francis Turner, Robert Browning, Bernd Linsmeier, Haidong Huang, Qiang Li, Kaid Darwiche, Lutz Freitag, Michael Simoff, Ioannis Kioumis, Konstantinos Zarogoulidis, Johannes Brachmann, Wolfgang Hohenforst-Schmidt, Paul Zarogoulidis, Thomas Vogl, J Francis Turner, Robert Browning, Bernd Linsmeier, Haidong Huang, Qiang Li, Kaid Darwiche, Lutz Freitag, Michael Simoff, Ioannis Kioumis, Konstantinos Zarogoulidis, Johannes Brachmann

Abstract

Introduction: Currently there are several advanced guiding techniques for pathoanatomical diagnosis of incidental solitary pulmonary nodules (iSPN): Electromagnetic navigation (EMN) with or without endobronchial ultrasound (EBUS) with miniprobe, transthoracic ultrasound (TTUS) for needle approach to the pleural wall and adjacent lung and computed tomography (CT) -guidance for (seldom if ever used) endobronchial or (common) transthoracical approach. In several situations one technique is not enough for efficient diagnosis, therefore we investigated a new diagnostic technique of endobronchial guided biopsies by a Cone Beam Computertomography (CBCT) called DynaCT (SIEMENS AG Forchheim, Germany).

Method and material: In our study 33 incidental solitary pulmonary nodules (iSPNs) (28 malignant, 5 benign; mean diameter 25 +/-12mm, shortest distance to pleura 25+/-18mm) were eligible according to in- and exclusion criteria. Realtime and onsite navigation were performed according to our standard protocol.22 All iSPN were controlled with a second technique when necessary and clinical feasible in case of unspecific or unexpected histological result. In all cases common guidelines of treatment of different iSPNs were followed in a routine manner.

Results: Overall navigational yield (ny) was 91% and diagnostic yield (dy) 70%, dy for all accomplished malignant cases (n=28) was 82%. In the subgroup analysis of the invisible iSPN (n=12, 11 malignant, 1 benign; mean diameter 15+/-3mm) we found an overall dy of 75%. For the first time we describe a significant difference in specifity of biopsy results in regards to the position of the forceps in the 3-dimensional volume (3DV) of the iSPN in the whole sample group. Comparing the specifity of biopsies of a 3D-uncentered but inside the outer one third of an iSPN-3DV with the specifity of biopsies of centered forceps position (meaning the inner two third of an iSPN-3DV) reveals a significant (p=0,0375 McNemar) difference for the size group (>1cm) of 0,9 for centered biopsies vs. 0,3 for uncentered biopsies. Therefore only 3D-centered biopsies should be relied on especially in case of a benign result.

Conclusion: The diagnostic yield of DynaCT navigation guided transbronchial biopsies (TBB) only with forceps is at least up to twofold higher than conventional TBB for iSPNs <2cm. The diagnostic yield of DynaCT navigation guided forceps TBB in invisible SPNs is at least in the range of other navigation studies which were performed partly with multiple navigation tools and multiple instruments. For future diagnostic and therapeutic approaches it is so far the only onsite and realtime extrathoracic navigation approach (except for computed tomography (CT)-fluoroscopy) in the bronchoscopy suite which keeps the working channel open. The system purchase represents an important investment for hospitals but it is a multidisciplinary and multinavigational tool with possible access via bronchial airways, transthoracical or vascular approach at the same time and on the same table without the need for an expensive disposable instrument use.

Keywords: ENB); cone-beam computed tomography (CBCT); electromagnetic navigation bronchoscopy (EMN; solitary pulmonary nodule; transbronchial biopsy (TBB)..

Conflict of interest statement

Conflict of Interest: WHS and JB receive honorary for studies with SIEMENS.

Figures

Figure 1
Figure 1
In big SPN: Accuracy in regards to diagnosis is a question of detection AND positionning intratumoral. In regards to navigation accuracy is defined by detection only. (intratumoral = inside/borderline or centered) In small SPN

Figure 2

Statistics along with navigation.

Figure 2

Statistics along with navigation.

Figure 2
Statistics along with navigation.

Figure 3

Statistical analysis.

Figure 3

Statistical analysis.

Figure 3
Statistical analysis.

Figure 4

Where is the place for…

Figure 4

Where is the place for DynaCT in Interventional Chest Medicine ?

Figure 4
Where is the place for DynaCT in Interventional Chest Medicine ?

Figure 5

CT-dataset in XR: 3-dimensional volume…

Figure 5

CT-dataset in XR: 3-dimensional volume information projected into c-arm fluoroscopy.

Figure 5
CT-dataset in XR: 3-dimensional volume information projected into c-arm fluoroscopy.

Figure 6

Applying 3-dimensional DynaCT dataset: 'Dotting'…

Figure 6

Applying 3-dimensional DynaCT dataset: 'Dotting' a pathway in virtual endoscopy or standard CT-projections…

Figure 6
Applying 3-dimensional DynaCT dataset: 'Dotting' a pathway in virtual endoscopy or standard CT-projections towards the target up to the 12th segmentation.

Figure 7

Advancing an iSPN by a…

Figure 7

Advancing an iSPN by a navigation device along the 3D-overlay: Distortion of the…

Figure 7
Advancing an iSPN by a navigation device along the 3D-overlay: Distortion of the airway due to navigation force.

Figure 8

Applying 3-dimensional DynaCT-dataset: Outlining the…

Figure 8

Applying 3-dimensional DynaCT-dataset: Outlining the target in 3 standard axis.

Figure 8
Applying 3-dimensional DynaCT-dataset: Outlining the target in 3 standard axis.
All figures (8)
Figure 2
Figure 2
Statistics along with navigation.
Figure 3
Figure 3
Statistical analysis.
Figure 4
Figure 4
Where is the place for DynaCT in Interventional Chest Medicine ?
Figure 5
Figure 5
CT-dataset in XR: 3-dimensional volume information projected into c-arm fluoroscopy.
Figure 6
Figure 6
Applying 3-dimensional DynaCT dataset: 'Dotting' a pathway in virtual endoscopy or standard CT-projections towards the target up to the 12th segmentation.
Figure 7
Figure 7
Advancing an iSPN by a navigation device along the 3D-overlay: Distortion of the airway due to navigation force.
Figure 8
Figure 8
Applying 3-dimensional DynaCT-dataset: Outlining the target in 3 standard axis.

References

    1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007;57(1):43–66.
    1. Kushi LH, Byers T, Doyle C. et al. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2006;56(5):254–281.
    1. Comstock GW, Vaughan RH, Montgomery G. Outcome of solitary pulmonary nodules discovered in an x-ray screening program. N Engl J Med. 1956;254(22):1018–1022.
    1. MacMahon H, Austin JH, Gamsu G. et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395–400.
    1. Goeckenjan G, Sitter H, Thomas M. et al. [Prevention, diagnosis, therapy, and follow-up of lung cancer. Interdisciplinary guideline of the German Respiratory Society and the German Cancer Society--abridged version] Pneumologie. 2011;65(8):e51–75.
    1. Henschke CI, McCauley DI, Yankelevitz DF. et al. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet. 1999;354(9173):99–105.
    1. Zwirewich CV, Vedal S, Miller RR, Muller NL. Solitary pulmonary nodule: high-resolution CT and radiologic-pathologic correlation. Radiology. 1991;179(2):469–476.
    1. Nathan MH, Collins VP, Adams RA. Differentiation of benign and malignant pulmonary nodules by growth rate. Radiology. 1962;79:221–232.
    1. Aberle DR, Berg CD, Black WC. et al. The National Lung Screening Trial: overview and study design. Radiology. 2011;258(1):243–253.
    1. Paesmans M, Berghmans T, Dusart M. et al. Primary tumor standardized uptake value measured on fluorodeoxyglucose positron emission tomography is of prognostic value for survival in non-small cell lung cancer: update of a systematic review and meta-analysis by the European Lung Cancer Working Party for the International Association for the Study of Lung Cancer Staging Project. J Thorac Oncol. 2010;5(5):612–619.
    1. Fischer B, Lassen U, Mortensen J. et al. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med. 2009;361(1):32–39.
    1. Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36–41.
    1. Huang CT, Ho CC, Tsai YJ, Yu CJ, Yang PC. Factors influencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesions. Respirology. 2009;14(6):859–864.
    1. Bilaceroglu S, Kumcuoglu Z, Alper H. et al. CT bronchus sign-guided bronchoscopic multiple diagnostic procedures in carcinomatous solitary pulmonary nodules and masses. Respiration. 1998;65(1):49–55.
    1. Hohenforst-Schmidt W, Banckwitz R, Zarogoulidis P, Vogl T, Darwiche K, Goldberg E, Huang H, Simoff M, Li Q, Browning R, Freitag L, Turner JF, Le Pivert P, Yarmus L, Zarogoulidis K, Brachmann J. Radiation Exposure of Patients by Cone Beam CT during Endobronchial Navigation - A Phantom Study. Journal of Cancer. 2014;5(3):192–202.
    1. Orth RC, Wallace MJ, Kuo MD. C-arm cone-beam CT: general principles and technical considerations for use in interventional radiology. J Vasc Interv Radiol. 2008;19(6):814–820.
    1. Schreiber G, McCrory DC. Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence. Chest. 2003;123(1 Suppl):115S–128S.
    1. Shure D. Transbronchial biopsy and needle aspiration. Chest. 1989;95(5):1130–1138.
    1. Shure D. Transbronchial needle aspiration--current status. Mayo Clin Proc. 1989;64(2):251–254.
    1. Xin-Wei H, De-chao J, Gang W, Ji F, Ming-ti F. The initial application of C-arm computed tomography guided percutaneous biopsy of lung lesions. Vol poster C-1137. ECR 20122012.
    1. Cheung JY, Kim Y, Shim SS, Lim SM. Combined fluoroscopy- and CT-guided transthoracic needle biopsy using a C-arm cone-beam CT system: comparison with fluoroscopy-guided biopsy. Korean J Radiol. 2011;12(1):89–96.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する