CT Guided Electromagnetic Navigational Bronchoscopy Duke Thoracoscopic Lobectomy Workshop March 21, 2018 Thomas A. D Amico MD Gary Hock Professor of Surgery Chief Thoracic Surgery, Chief Medical Officer Duke Cancer Institute
Consultant for Scanlan Disclosures No conflicts related to this presentation
Electromagnetic Navigational Bronchoscopy Distal bronchoscopic and trans-bronchoscopic navigation based on registration of CT scans with proximal bronchoscopy Provides multi-dimensional views during navigation: axial, coronal, sagittal, local Guides the placement of the tip of the navigation catheter within 3-4 mm of the target
Goals of ENB 1. Biopsy (needle, core, brush, forceps) 2. Marking small lesions with dye or fiducials for resection 3. Ablation
AUTOMATIC REGISTRATION Process in which the system gradually learns the shape of the lung by continuously recording the position of the locatable guide as it moves through the anatomy
AUTOMATIC REGISTRATION Process in which the system gradually learns the shape of the lung by continuously recording the position of the locatable guide as it moves through the anatomy
AUTOMATIC REGISTRATION Process in which the system gradually learns the shape of the lung by continuously recording the position of the locatable guide as it moves through the anatomy
AUTOMATIC REGISTRATION Process in which the system gradually learns the shape of the lung by continuously recording the position of the locatable guide as it moves through the anatomy
MANUAL REGISTRATION Manual registration correlates the location of the locatable guide to a known anatomical landmark from a marked location in the CT scan 6 locations are identified: Main carina Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe Manual registration is used when a 3D Map is not available or when the patient has atypical anatomy.
BEST PRACTICE FOR AUTOMATIC REGISTRATION PREPARE 1. Extend the navigation catheter 10 mm beyond the end of the bronchoscope. 2. Position the end of the bronchoscope mid-trachea (e.g., 4-5 cm) above the main carina.
BEST PRACTICE FOR AUTOMATIC REGISTRATION PREPARE 1. Extend the navigation catheter 10 mm beyond the end of the bronchoscope. 2. Position the end of the bronchoscope mid-trachea (e.g., 4-5 cm) above the main carina.
BEST PRACTICE FOR AUTOMATIC REGISTRATION PERFORM A BALANCED SURVEY Advance the bronchoscope 3 cm into two segments of the RUL, RML, RLL, LUL and LLL 2 Segments 1-2 Segments 2 Segments 2 Segments 2 Segments
BEST PRACTICE FOR AUTOMATIC REGISTRATION REVIEW FEEDBACK Review the checkmarks on the lung illustration after completing the balanced survey If a checkmark is missing, revisit the area and collect additional data
BEST PRACTICE FOR AUTOMATIC REGISTRATION VERIFICATION 1. Verify alignment on the CT views 2. Verify on at least two carinas along the planned pathway, preferably until the bronchoscope approaches a wedged position
BEST PRACTICE FOR AUTOMATIC REGISTRATION VERIFICATION 3. Continue verification in Registration Review. Verify the registration samples are aligned to the 3D Map.
GenCut Needle
Axial CT Local Coronal CT Sagital CT
15 trials were included (1,033 lung nodules) Definitive dx obtained after 65% of ENB Overall diagnostic accuracy was 74% PTX in 3.1% of patients, requiring treatment Variables with higher yields: upper/middle lobes, nodule size, bronchus sign, radial EBUS, catheter suctioning, general anesthesia, and ROSE
Accuracy for Malignancy
Khandhar et al. BMC Pulmonary Medicine (2017) 17:59 Bx (964), fiducial (210), dye (17), LN (334) General anesthesia in 80% Tissue obtained in 94%, malignant 46%, nonmalignant 41%, inconclusive 13% Tissue adequacy for genetic testing was 80% PTX 5%, hemorrhage 1%, resp failure 0.6% 1-month f/u not sufficient to calculate the true negative rate or diagnostic yield
1289 patients 15 academic sites 12 private facilities 10 mixed facilities in Europe and North America
CT-Guided Navigational Bronchoscopy Fluoroscopy is limited 2-dimensional Small lesions are difficult to visualize Ground glass opacities are impossible to visualize CT-Guided ENB may improve success rate of biopsy and may be used in the future for ablation
CT Options 1. Cone beam CT 2. Airo Mobile Intraoperative CT 3. Dedicated CT
Airo Mobile Intraoperative CT
CT Garage
CT propeller CT Garage
CT propeller un CT compatible bed CT Garage
CT propeller Anesthesia Ventilator CT compatible bed CT Garage
Case 68 year old man with a mixed GGO CT-guided biopsy negative Anatomically unsuitable for segmentectomy High-risk surgical candidate to proceed with lobectomy without a diagnosis
Lesion Catheter
Lesion Catheter
Cross Country
Emprint Microwave Ablation System with Thermosphere Technology Thermal control: minimizes uncontrolled thermal factors that contribute to a passive ablation zone Field control: delivers a precise, scalable spherical field Wavelength control: prevents wavelength elongation as tissue becomes desiccated or charred and its properties change during ablation
CHEST 2017; 151(3):674-685 Intra-tumoral chemotherapy or gene therapies
CT Guided ENB Facilitates precise location of nodules for biopsy Would be mandatory for ablation Cross-country trans-bronchoscopic technology will improve the ability to biopsy, mark or ablate more lesions
The Future CT screening: Higher proportion of early stage patients, and preoperative biopsy is needed in a subgroup Some patients may elect for resection; others may choose ablation Thoracic surgeons should be able to diagnose, stage, resect, and ablate lung cancer