Navigational Bronchoscopy

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Navigational Bronchoscopy
Kazuhiro Yasufuku   Director, Interventional
Thoracic Surgery Program Assistant Professor,
University of Toronto Division of Thoracic
Surgery, Toronto General Hospital
2012 Lung Cancer Summit Focus on Thoracic
Surgery Lung Cancer
Boston Marriott Copley Place, Boston,
MA November 16th, 2012
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Disclosure

• Educational and research grants from Olympus
  Medical Systems Corp.
• Consultant for Olympus America Inc.
• Consultant for Intuitive Surgical Inc.
• Novadaq Corp.
• Veran Medical Technologies

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Diagnosis and Management of Lung CaACCP
GUIDELINES (2nd Edition)

• Until further progress is made in guidance of
  bronchoscopy, peripheral nodules that do not have
  a CT-bronchus sign should be pursued with TTNA.
  In addition, routine preoperative bronchoscopy is
  not recommended in the patient with an SPN,
  because it has been shown rarely to change stage
  and obviate the need for surgery

Gould et al, CHEST 2007 132108s
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Diagnosis of Peripheral Lung Nodules (lt2cm)

• Surgical Resection
• 720/1467 49 Benign Hoffmann 2001
• CT Screening
• 98 Benign Midthun 2003
• Bronchoscopy (Fluoroscopic guidance)
• Poor visualization of lesion
• No pathway imaging
• Steering of tools difficult
• Yield 10-50

Cortese et al, Chest 2000 1171049 Nadich et al,
1988 93595 Gould et al, Chest 2007
132108s Shinagawa et al, Chest 2004 125 1138
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Improving the Yield Radial EBUS
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EBUS-GS
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Electromagnetic Navigation (EMN)

• inReach system, (superDimension Ltd)

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Real-time Location Information
Miniaturized sensor
Electromagnetic Location Board
Real-time delivery of information 166/sec
Generation of electromagnetic waves
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Electromagnetic Navigation

• Diagnostic yield
• SPNlt30mm 54-75
• Limitation
• registration error (3-8mm)
• not real-time sampling
• expensive

Schwartz et.al., Chest 2006 129 988 Gildea et
al, Am J Respir Crit Care Med 2006 174
982 Eberhardt et al, CHEST 2007
1311800 Eberhardt et al, AJRCCM 2007 176
36 Eberhardt et al, AJRCCM 2007 176 36
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EMN EBUS-GS
Eberhardt et al, AJRCCM 2007 176 36
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Virtual Bronchoscopy Navigation (VBN)

• Olympus BF Navigation

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Olympus BF Navigation
Courtesy Dr. Fumio Asano
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VBNEBUS-GS vs EBUS-GS (V-NINJYA Study)

• Multicentre, randomized control study
• Small peripheral nodules (lt 3cm)
• Dx yield higher in VBN group
• 80.4 vs 67.0 (p0.032)
• Shorter time in VBN group
• 24.0min vs 26.2min (p0.016)

Asano et al, Thorax 2011 66 1072
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VBN/EMN Spin Drive (Veran Medical Technologies)
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Spin Drive Planning
Select Target Autopath
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Spin Drive Planning
Virtual flythrough evaluation
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Spin Drive Navigation
Steerable Catheter (OD 3mm, 2mm working channel)
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Why do TS need to do Transbronchial Biopsies?
Image guided therapeutics

• Bronchoscopic RFA

• ENB-guided VATS wedge resection of peripheral
  lung nodules

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TRIGOR ATranslational Research Image Guided OR
Cone-Beam CT
Dual Source- Dual Energy CT
MIS, Endoscopic Technology
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TRIGOR A Capabilities
Cone-Beam CT
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TRIGOR A
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Summary

• Navigational Bronchoscopy
• Continues to evolve
• Registration error
• Moderate yields
• Inferior to CT-TTNA
• Not real-time sampling
• Expensive (1K/forceps)

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Division of Thoracic Surgery Toronto General
Hospital University Health Network Kazuhiro
Yasufuku, MD, PhD, FCCP kazuhiro.yasufuku_at_uhn.ca
Thank you