A. Cheng4, C. C. Moodie1, J. R. Garrett1, E. M. Toloza1,2,3 1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA
Introduction: We evaluated outcomes of electromagnetic navigational bronchoscopy (ENB) performed by a thoracic surgeon.
Methods: We retrospectively analyzed all patients who underwent ENB by one thoracic surgeon. ENB was performed for transbronchial biopsies (TBBx) of or for metal or dye-mark fiducial placement at peripheral lung nodules, the latter immediately followed by minimally invasive resection.
Results: Of 142 pts who underwent ENB from November 2013 to October 2015, 40 (28.2%) and 111 (78.1%) pts underwent ENB for TBBx or for fiducial placement, respectively. Only 4/142 (2.8%) pts underwent ENB with C-arm fluoroscopy. A total of 303 lung nodules were targeted in the right upper lobe [RUL] (83/303, 27.4%), right middle lobe (41/303, 13.5%), right lower lobe [RLL] (77/303, 25.4%), left upper lobe (44/303, 14.5%), and left lower lobe (58/303, 19.1%), with a mean of 2.1+0.1 (range 1-8) lung nodules per pt. Of these lung nodules, 62/303 (20.5%) and 237/303 (78.2%) were targeted for TBBx or for fiducial placement, respectively, while 4/303 (1.3%) lung nodules were targeted for both TBBx and fiducial placement. Navigation was successful to 298/303 (98.3%) lung nodules, with 5/303 (1.7%) unsuccessful navigations to the RUL (3/5, 60%) and the RLL (2/5, 40%). Of 40 pts who underwent ENB-guided TBBx, 5/40 (12.5%) pts also underwent transbronchial confocal laser endomicroscopy. A mean of 1.6+0.1 (range 1-4) lung nodules were biopsied per pt, with needle aspiration used in 29/40 (72.5%) pts, brushings in 38/40 (95.0%) pts, forceps biopsies in 41/41 (100%) pts, and bronchial lavage in 29/40 (72.5%) pts. One pt (1/40, 2.5%) had a pneumothorax, and two pts (2/40, 5.0%) had endobronchial bleeding requiring bronchial lavage with cold saline containing 1:100,000 dilution of epinephrine. Of 111 pts who underwent ENB for fiducial placement, 22/111 (19.8%) pts also underwent intraoperative ultrasound. Two of 111 (1.8%) and 111/111 (100%) pts underwent metal or dye-mark fiducial placement, respectively, with a mean of 2.2+0.1 (range 1-7) dye-marks per pt. Indigo carmine was used in 1/111 (0.9%) pts, methylene blue in 111/111 (100%) pts, and indocyanine green in 91/111 (82.0%) pts. Eight of 111 (7.2%) and 104/111 (93.7%) pts underwent video-assisted thoracoscopy (VATS) or robotic-assisted VATS wedge resection, respectively, with a mean of 1.1+0.1 (range 1-3) wedge resections per lung nodule target. The only ENB-related complication occurring in this latter group of pts was retention of a metal fiducial that was later coughed up by the pt. No pts underwent VATS anatomic resection, but 10/111 (9.0%) and 21/111 (18.9%) pts underwent immediate robotic-assisted segmentectomy or lobectomy, respectively.
Conclusions: ENB to small peripheral lung nodules is safe and useful for thoracic surgeons to perform TBBx or to place metal or dye-mark fiducials, the latter immediately followed by VATS lung resection without or with robotic assistance.