Case Details

Lesion Characteristics

Lesion Size (diameter): 13 mm

Lesion Location: Lower Upper Lobe Lesion (Lingular)

Bronchus Sign: Yes

Visible on Fluoro: Yes

Case Information

Full Procedure Time: 55 minutes

REBUS Verification: Concentric

Final Pathology Report: Carcinoid

Background

A 61 year-old female with a history of COPD and tobacco use presented with an 11mm inferior lingular nodule in January 2021. Laboratory analysis demonstrated normal white blood cell count, negative coccidioides antibodies, acid fast cultures, fungal serologies, quantiferon TB test and urine histoplasmosis antigen. Navigational bronchoscopy was initially performed in February 2021. Radial EBUS (r-EBUS) was used intra-procedure and a concentric density was identified. However, rapid on-site evaluation (ROSE) cytology was negative for malignant cells with inconclusive pathology. CT scan in April 2021 showed growth of the lingular nodule to 12 mm. Interventional radiology was consulted and TTNA was performed. Pathology was again inconclusive. After further discussion with the patient about newer modalities she was still interested in a bronchoscopic method for resection rather than surgery. In October 2021, a robotic-assisted bronchoscopy procedure utilizing LungVision® for AI-driven advanced real-time imaging in conjunction was scheduled.

The Procedure

A pre-operative CT was used for planning on both the Ion by Intuitive robotic bronchoscope and the LungVision® advanced imaging systems. Both systems were registered, the Ion catheter introduced into the airway, and the catheter navigated to the target as defined by the robotic platform’s shape-sensing technology. Once the Ion catheter was within 10mm of the target, the proximity of the bronchoscope to the pleura was enough of a concern that a GE OEC 9900 Elite C-arm was brought into position over the patient and an AI Tomography® scan with the LungVision® system performed to determine true lesion location. The updated lesion location overlayed onto the LungVision® augmented fluoroscopy showed that the catheter was positioned 10mm past the actual lesion. Ion shape-sensing navigation indicated that the system believed that the proximal edge of the lesion was still 10mm further out, equating to an approximate 20mm (2cm) of CT-to-body divergence (Figure 2).

The Ion catheter was retracted to the lesion location as intraoperatively visualized by LungVision®. Once the Ion catheter was repositioned to where LungVision® showed the lesion to be, the Ion vision probe was retracted from the bronchoscope and replaced with a radial endobronchial ultrasound (r-EBUS) probe. The r-EBUS probe showed a concentric echo-density (Figure 3), verifying that the lesion location as shown by LungVision® was correct and that the repositioned catheter was now at the lesion. The r-EBUS probe was retracted and replaced by biopsy tools. Under augmented fluoroscopy which showed both lesion boundaries and biopsy tool location in real-time, Dr. Nobari was able to acquire biopsy samples and ensure that those samples were from within the lesion (Figure 4). Rapid On-Site Evaluation (ROSE) assessed that samples collected via needle biopsy were adequate and consistent with a carcinoid (Figure 5). This was later confirmed by cytology on the final pathology report.

Conclusion

This case demonstrates the value of Body Vision Medical’s LungVision® AI-driven real-time imaging technology. While the benefits of Ion’s robotic catheter – namely thin outer diameter (OD), stability, and articulation – provide tangible benefits during navigation bronchoscopy, its reliance on a pre-operative CT for establishing a virtual navigation target makes it susceptible to CT-to-body divergence and does not provide the ability to visually confirm that biopsy samples are acquired from within the lesion. Thus, the addition of LungVision ® intraoperative imaging proved crucial for navigating to the actual lesion location and enabled image-guided sampling of this peripheral pulmonary nodule.

About Dr. Matthew M. Nobari MD

Matthew M. Nobari MD

Intervetinoal Pulmonologist

Associate Professor of Medicine

Loyola University Chicago

Chicago, IL, USA