cone beam ct bronchoscopy: a paradigm shift...anatomy during guided bronchoscopy accepted for...

CONE BEAM CT BRONCHOSCOPY: A PARADIGM SHIFT

KRISH BHADRA, MDCOMMON SPIRIT NATIONAL LUNG COUNCIL CO-CHAIR

GO2 LUNG CANCER FOUNDATION SCIENTIFIC

LEADERSHIP BOARD

DISCLOSURES

Boston ScientificMerit MedicalVeracytePhilips Noah Medical

Medtronic ILSSiemensBodyVisionIntuitiveBiodesix

LUNG NODULE BIOPSIES

IT’S DIFFICULT

HARD TO REACH PLACES

THE LUNG MOVES!

SMALL TARGETS

"You jump in the water, and if you don't have goggles or gear, you can't see the quarter — you're just

groping around blindly," said Rickman, director of interventional pulmonology at Vanderbilt University

Medical Center. "Fortunately, there's somebody who's pioneering the way for this type of lung

biopsy, and he happens to be right here in Chattanooga."

Northwestern

Dr. Gillespie

Dr. Argento

Vanderbilt

Dr. Rickman

Dr. Maldonado

Tulane

Dr. Kheir

Ohio State

Dr. Pannu

Stanford

Dr. Bedi

Harvard

Dr. Panchabhai

VISITING PROFESSORSBaylor

Dr. Jiwani

UCSF Fresno

Dr. Hegde

MD Anderson

Banner

Dr. Shah

IMPORTANCE OF REAL-TIME

CONFIRMATION

Limitations of standard fluoroscopy

• 75 consecutive patients (retrospective)

• 93 lesions

• 15 patients with multiple lesions

• 10 patients with bilateral lesions

• Median lesion size: 16.0mm

• Bronchus sign present in only 39% of cases

• 49% of lesions visible on standard fluoroscopy

CONE-BEAM CT WITH AUGMENTED FLUOROSCOPY AND ENB JOURNAL OF BRONCHOLOGY AND INTERVENTIONAL PULMONOLOGY 2018, VOLUME 25, NUMBER 4, 273-281

Pritchett, et al. Journal of bronchology and interventional pulmonology 2018, Volume 25, number 4, 273-281

CONE-BEAM CT WITH AUGMENTED FLUOROSCOPY AND ENB JOURNAL OF BRONCHOLOGY AND INTERVENTIONAL PULMONOLOGY 2018, VOLUME 25, NUMBER 4, 273-281

Diagnostic Accuracy**

All lesions 93.5%

<10mm (n=19) 89.5%%

<20mm (n=65). 90.8%

>20mm (n=27). 100%

Negative Predictive Value

79.3% - 89.7%

Average CBCT scans per case: 1.5

Average effective dose of 2.0 mSv per CBCT scan

**Diagnostic accuracy represents the malignant and benign lesions as well as the indeterminate lesions confirmed as benign with clinical

and radiographic follow-up divided by the total number of lesions biopsied.

NAVIGATE Thin Scope/rEBUS CBCT/AF/ENB

Yield: 73% Yield: 49% Yield: 94%

20mm31mm

16mm

Median Lesion: 20mm Median Lesion: 31mm Median Lesion: 16mm

MEDIAN LESION SIZE VS. YIELD IN VARIOUS STUDIES

ADVANTAGES OF BRONCHOSCOPY OVER CT FNA

Lower morbidity

Lower mortality

Reduced length of stay

Lower risk of pneumothorax

Allows for mediastinal staging

PAIN POINTS: COST AND RADIATION

EFFECTIVE DOSE OF COMMON PROCEDURES

CTA (PE protocol): 15 mSv

Nuclear Cardiac Stress Test: 9.4 – 12.8 mSv

Cardiac EP Study: 15-39 mSv (per hour)

CT Chest Inspiration/Expiration (i.e. for Veran): 9.5 mSv

Diagnostic Heart Cath: 9-14 mSv

Therapeutic Heart Cath: 15 – 25 mSv

RADIATION DOSE DURING CBCT-GUIDED ENB

FOR DIAGNOSIS OF PULMONARY NODULES

Sputum

Cytology

Traditional

Bronchoscopy

EBUS

Navigation

CTFNA

Thoracic

Surgery

VATS Lung Bx

DIAGNOSTIC YIELD

INVA

SIV

EN

ESS

DIAGNOSTIC YIELD AND

INVASIVENESS

CBCT

Bronch

RESEARCH FOR 2020Papers

Virtual or reality: Divergence between preprocedural computed tomography scans and lung

anatomy during guided bronchoscopy

Accepted for Publication to JTD

Electromagnetic Navigation Bronchoscopy with advanced fluoroscopy-based localization and

intraprocedural local registration for the evaluation of peripheral pulmonary

Submitted to JOBIP

Systematic Review and Meta-Analysis on Proteomic Testing

Submitted to Chest

Active Research Trials

BodyVision Phase 1 trial

Pending Research Trials

Lung Vision multicenter trial

Pulmera CBCT Imaging Trial

Lung Navigation Ventilation Protocol

VERITAS: CT Guided FNA versus Navigational Bronchoscopy Non-inferiority Study