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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.

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Navigational Bronchoscopy


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    1. 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

    2. 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

    3. Diagnosis and Management of Lung Ca:ACCP 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; 132:108s

    4. Diagnosis of Peripheral Lung Nodules (<2cm) • 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; 117:1049 Nadich et al, 1988; 93:595 Gould et al, Chest 2007; 132:108s Shinagawa et al, Chest 2004; 125: 1138

    5. UM-3R (O.D. = 2.5mm) UM-S20-20R (O.D. = 1.7mm) Improving the Yield: Radial EBUS

    6. EBUS-GS

    7. Electromagnetic Navigation (EMN) • inReach system, (superDimension Ltd)

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

    9. Electromagnetic Navigation • Diagnostic yield • SPN<30mm: 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; 131:1800 Eberhardt et al, AJRCCM 2007; 176: 36 Eberhardt et al, AJRCCM 2007; 176: 36

    10. EMN + EBUS-GS Eberhardt et al, AJRCCM 2007; 176: 36

    11. Virtual Bronchoscopy Navigation (VBN) • Olympus BF Navigation

    12. Olympus BF Navigation Courtesy Dr. Fumio Asano

    13. VBN+EBUS-GS vs EBUS-GS (V-NINJYA Study) • Multicentre, randomized control study • Small peripheral nodules (< 3cm) • Dx yield higher in VBN group 80.4% vs 67.0% (p=0.032) • Shorter time in VBN group 24.0min vs 26.2min (p=0.016) Asano et al, Thorax 2011; 66: 1072

    14. VBN/EMN: Spin Drive (Veran Medical Technologies)

    15. Spin Drive Planning Select Target: Autopath

    16. Spin Drive Planning Virtual flythrough evaluation

    17. Spin Drive Navigation Steerable Catheter (OD 3mm, 2mm working channel)

    18. Why do TS need to do Transbronchial Biopsies? • Bronchoscopic RFA • ENB-guided VATS wedge resection of peripheral lung nodules Image guided therapeutics Chest. 2010 Apr;137(4):890-7 Seminars in Thoracic and Cardiovascular Surgery, Vol 22 (2), 2011

    19. TRIGOR ATranslational Research Image Guided OR Cone-Beam CT Dual Source- Dual Energy CT MIS, Endoscopic Technology Guided Therapeutics (GTx) Core

    20. TRIGOR A Capabilities Cone-Beam CT Guided Therapeutics (GTx) Core

    21. TRIGOR A

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

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