Bronchoscopic transparenchymal nodule access in the diagnosis and management of pulmonary nodules

摘要

To the Editor: Transthoracic needle aspiration (TTNA) and bronchoscopy have been the preferred methods for the sampling of pulmonary nodules suspected of lung cancer. However, despite having a higher diagnostic accuracy, TTNA has been associated with a high rate of pneumothorax. Moreover, conventional bronchoscopy with a low rate of pneumothorax has exhibited a low diagnostic yield for peripheral pulmonary nodules, particularly for nodules <2 cm in size or those without a bronchus leading directly to them. Thus, Herth et al[1] developed a novel bronchoscopy technique called bronchoscopic transparenchymal nodule access (BTPNA) under the guidance of Archimedes Virtual Bronchoscopic Navigation (VBN) System for the purpose of accessing pulmonary nodules using a transparenchymal approach without relying on the airway to approach the lesion. Here, we systematically reviewed evidence regarding BTPNA to provide general guidance on the safe implementation and development of this novel approach. Computed tomography (CT) data were uploaded onto the Archimedes System to construct a three-dimensional (3D) model of the bronchial airways, ribs and lungs, and vascular structures to mark and segment the lesion. Two point of entry (POE) locations with a straight, vessel-free path to the lesion, and a bronchoscopy path to the POE locations are created by the system. The system also shows the tunnel path from the POE on the airway wall to the target lesions. During surgery, the Archimedes System combines real-time fluoroscopic data with 3D CT data to guide the sheath from the POE on the airway wall through the lung parenchyma directly into the pulmonary nodule. On reaching the POE position, the core needle passes through the standard therapeutic bronchoscope working channel and penetrates the airway walls at the POE in the airway. Once the proximal end is reached, the stylet is removed, biopsy forceps are inserted through the sheath, and biopsy samples are taken under fused fluoroscopy guidance [Figure 1].[1]Figure 1: (A) Hardware requirements of the operation room. (B) Archimedes System calculates two suitable point of entry (POE) locations with straight line, vessel-free access to the SPN, as well as bronchoscopy paths for guiding the user's bronchoscope to the POE locations. (C) Sheath tip was advanced up to the lesion through the POE. (D–E) Guide sheath being advanced to the target under fluoroscopic guidance. SPN: Solitary pulmonary nodules.During pulmonary nodule biopsy, the diagnostic yield ranged from 38.5% to 80.0% based on a single or combination of different guided bronchoscopies, depending on the lesion size, location, and the presence of a bronchus sign (BS) on CT.[2] In a randomized trial, the 3-mm ultrathin bronchoscope provided higher diagnostic yields for pulmonary lesions than the 4-mm thin bronchoscope combined with radial endobronchial ultrasound, VBN, and fluoroscopy (70.1% vs. 58.7%).[3] Recently, a retrospective study showed that robot-assisted bronchoscopy appeared to be a promising approach, with a successful navigation yield of 88.6%, diagnostic yield of 69.1% to 77.0%, and pneumothorax rate of 3.6%.[4] However, these approaches were restricted to nodules in which a BS was present. Transbronchial needle aspiration (TBNA) and transbronchial biopsy (TBB) had a diagnostic yield of only 59.1% and 22.6%, respectively, with the diagnostic yield decreasing to 31% even when electromagnetic navigation bronchoscopy was used in lesions with no BS on CT. [5] In a prospective study, Sun et al[6] evaluated the safety and efficacy of BTPNA and TBNA using the Archimedes system to diagnose peripheral pulmonary lesions. These approaches guided by the Archimedes system had a higher diagnostic yield (72.8%–75.4%) than TBB in the lesions independent of the presence of BS and even a higher diagnostic yield (71.4%–74.1%) in lesions without a BS that cannot be directly reached by bronchoscopy. Moreover, BTPNA had a relatively higher biopsy yiel