Real-Time Image-Guided Cryobiopsy of a Right
Lower Lobe (RLL) Cavitary Lesion

Case Details

Lesion Characteristics

Lesion Size (diameter): 30 mm

Lesion Location: Right Lower Lobe (RLL)

Bronchus Sign: Yes

Visible on Fluoro: Yes

Case Information

Final Pathology Report: Squamous Cell Carcinoma

Background

A 74-year-old female patient presented with a growing cavernous mass in the apical

segment of her right lower lobe. The patient exhibited mild dyspnea and productive

coughing and had a significant smoking history of 75 pack-years. CT imaging revealed

a lesion with a maximal wall thickness of 0.8 cm and a positive bronchus sign. Given

the lesion’s challenging location—adjacent to the rib and mediastinum—a CT-guided

biopsy was deemed high-risk. A navigational bronchoscopy using the LungVision®

(Body Vision Medical) platform was selected for tissue sampling.

The Procedure

The bronchoscopy was performed under general anesthesia using the Artis Zee 2D

C-arm (Siemens) and an H-190 bronchoscope (Olympus). Augmented fluoroscopy

provided by LungVision facilitated precise localization of the lesion, although initial

attempts to obtain samples using standard forceps and needles were unsuccessful

due to acute angulation. A 1.1 mm cryoprobe (Erbe Medical) was successfully employed, and “tool-in-lesion” confirmation with LungVision validated accurate

positioning. Histopathology confirmed squamous cell carcinoma. The patient was

subsequently treated with chemotherapy and radiotherapy.

	Coronal	Axial	Sagittal
Pre-operative CT
LungVision AI Tomo intraoperative image

Fig 2. Paired images showing pre-operative CT scan of Right Lower Lobe (RLL) pulmonary lesion in coronal, axial, and sagittal planes and corresponding AI Tomo 3D tomographic images captured intraoperatively using LungVision prior to introduction of bronchoscope.

Fig 3. LungVision augmented fluoroscopy displays overlays of airways derived from the pre-operative CT, with magenta indicating the planned path to the lesion and teal representing other local bronchi, and yellow marking the lesion location as identified by the physician during the latest C-arm spin. The visualization confirms tool-in-lesion placement of the cryoprobe during tissue sampling. — ***Fig 3***. LungVision augmented fluoroscopy displays overlays of airways derived from the pre-operative CT, with magenta indicating the planned path to the lesion and teal representing other local bronchi, and yellow marking the lesion location as identified by the physician during the latest C-arm spin. The visualization confirms tool-in-lesion placement of the cryoprobe during tissue sampling.

Conclusion

This case demonstrates the utility of augmented fluoroscopy in navigating complex lung anatomy. The real time augmented fluoroscopy and imaging helped recognize the limitations of the standard tools and led to the use of the cryoprobe. The LungVision platform supports the use of most available biopsy tools, thus facilitating such multimodal sampling. In addition to the clinical benefits of enhancing diagnostic yield, Å we must also address the financial considerations when incorporating new technologies; Germany's hospital reimbursement system is based on the Diagnose-Related Group (DRG) system which pays a flat fee for each of these procedures. Technologies that require proprietary tools add to the per-procedure cost, particularly for a procedure such as diagnostic bronchoscopy for which the reimbursement rate is low, increasing the financial burden on the hospital. Thus, the value of being able to use standard tools and bronchoscopes with the LungVision platform cannot be overstated.

References

1. Verhoeven RLJ, Vos S, van der Heijden EHFM. Multi-modal tissue sampling in cone beam CT-guided navigation

bronchoscopy: comparative accuracy of different sampling tools and rapid on-site evaluation of cytopathology.

J Thorac Dis. 2021 Jul;13(7):4396-4406. doi: 10.21037/jtd-21-518.PMID: 34422366; PMCID: PMC8339773.

About Dr. Björn Schwick Dr. med. José Miguel Sodi Luna

Dr. Björn Schwick

Chief Physician

Department of Pulmonology

Luisenhospital Aachen

Aachen, Germany

Dr. med. José Miguel Sodi Luna

Senior Physician