Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules.

BACKGROUND: Small peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used to locate pulmonary nodules, but this method has many limitations. Thus, we aimed to evaluate the accuracy and feasibility of electromagnetic navigational bronchoscopy (ENB) with pleural dye to locate small peripheral pulmonary nodules before video-associated thoracic surgery (VATS). METHODS: The ENB localisation procedure was performed under general anaesthesia in an operating room. Once the locatable guide wire, covered with a sheath, reached the ideal location, it was withdrawn and 0.2-1.0 mL of methylene blue/indocyanine green was injected through the guide sheath. Thereafter, 20-60 mL of air was instilled to disperse the dye to the pleura near the nodules. VATS was then performed immediately. RESULTS: Study subjects included 25 patients with 28 nodules. The mean largest diameter of the pulmonary nodules was 11.8 mm (range, 6.0-24.0 mm), and the mean distance from the nearest pleural surface was 13.4 mm (range, 2.5-34.9 mm). After the ENB-guided localisation procedure was completed, the dye was visualised in 23 nodules (82.1%) using VATS. The average duration of the ENB-guided pleural dye marking procedure was 12.6 min (range, 4-30 min). The resection margins were negative in all malignant nodules. Complications unrelated to the ENB-guided localisation procedure occurred in two patients, including one case of haemorrhage and one case of slow intraoperative heart rate. CONCLUSION: ENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection. TRIAL REGISTRATION NUMBER: ChiCTR1900021963.

Enzyme replacement therapy for congenital hypophosphatasia allows for surgical treatment of related complex craniosynostosis: a case series.

Hypophosphatasia (HPP) is a rare inherited disorder of bone metabolism that results in the loss of function of the gene coding for tissue-nonspecific alkaline phosphatase (TNSALP). Patients with HPP have defective bone mineralization as well as craniosynostosis that can be seen in the infantile and childhood forms of this disease. Traditionally, HPP has had a poor prognosis, with few children surviving to exhibit the phenotype of clinical craniosynostosis that requires surgical intervention. Here, the authors report on new advancements in enzyme replacement therapy (ERT) for children affected by HPP, allowing these patients to survive and undergo surgery to address complex craniosynostosis. The authors discuss their case series of 4 HPP patients treated at their institution with ERT who have undergone successful surgical intervention for craniosynostosis. These children had no complications related to their surgeries and exhibited decreased neurological symptoms following cranial vault remodeling. This study reveals that ERT administered either pre- or post- operatively paired with cranial vault remodeling strategies can yield improved neurological outcomes in children affected by HPP.

AB044. Leptomeningeal metastatic esthesioneuroblastoma: a systematic review with case illustration.

BACKGROUND: Esthesioneuroblastomas (ENBs) represent a rare subset of malignancies originating within the upper aerodigestive tract, characterized by a propensity for local metastasis to the intracranial compartment through the cribriform plate. These neoplasms are frequently associated with a high incidence of local recurrence subsequent to therapeutic intervention. In this report, we review the literature and present a case of a patient with extensive meningeal and leptomeningeal dissemination of ENB, with a survival period of 2 years. METHODS: A systematic review of literature was conducted in accordance with the PRISMA guidelines. Additionally, the presentation, surgical management, chemotherapy, and outcomes of a 60-year-old female presenting with extensive meningeal metastasis at onset. RESULTS: Following the literature review, 43 distinct works were identified, extracted variables from the remaining seven papers that met our inclusion criteria included demographic data, presenting symptoms, recurrence status, primary tumor location, location of Leptomeningeal metastasis of ENB, interval from initial treatment to recurrence, initial treatment approach, treatment-related complications, survival outcomes, and post-treatment status of patients. The average age at diagnosis was 52.6 years (range, 31-76 years), with females comprising 63.6% of the sample. The majority underwent gross-total resection and received adjuvant radiotherapy as initial therapy. The median time to intracranial metastasis was 57 months post-primary tumor diagnosis. The median overall survival for ENB with intracranial metastasis was 14 months. CONCLUSIONS: ENB exhibits a marked propensity for recurrence and can metastasize to the intracranial space years post-remission, which correlates with reduced survival. Therefore, perpetual radiographic surveillance is warranted for all ENB patients to detect late recurrences and intracranial spread promptly.

Diagnostic yield using electromagnetic navigation bronchoscopy for peripheral pulmonary nodules <2 cm.

BACKGROUND: Although electromagnetic navigation bronchoscopy (ENB) is highly sensitive in the diagnosis of peripheral pulmonary nodules (PPNs), its diagnostic yield for subgroups of smaller PPNs is under evaluation. OBJECTIVES: Diagnostic yield evaluation of biopsy using ENB for PPNs <2 cm. DESIGN: The diagnostic yield, sensitivity, specificity, positive predictive value, and negative predictive value of the ENB-mediated biopsy for PPNs were evaluated. METHODS: Patients who had PPNs with diameters <2 cm and underwent ENB-mediated biopsy between May 2015 and February 2020 were consecutively enrolled. The final diagnosis was made via pathological examination after surgery. RESULTS: A total of 82 lesions from 65 patients were analyzed. The median tumor size was 11 mm. All lesions were subjected to ENB-mediated biopsy, of which 29 and 53 were classified as malignant and benign, respectively. Subsequent segmentectomy, lobectomy, or wedge resection, following pathological examinations were performed on 64 nodules from 57 patients. The overall sensitivity, specificity, positive predictive value, and negative predictive value for nodules <2 cm were 53.3%, 91.7%, 92.3%, and 51.2%, respectively. The receiver operating curve showed an area under the curve of 0.721 (p < 0.001). Additionally, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.5%, 100%, 100%, and 42.9%, respectively, for nodules with diameters equal to or larger than 1 cm; and 30.8%, 86.7%, 66.7%, and 59.1%, respectively, for nodules less than 1 cm. In the subgroup analysis, neither the lobar location nor the distance of the PPNs to the pleura affected the accuracy of the ENB diagnosis. However, the spiculated sign had a negative impact on the accuracy of the ENB biopsy (p = 0.010). CONCLUSION: ENB has good specificity and positive predictive value for diagnosing PPNs <2 cm; however, the spiculated sign may negatively affect ENB diagnostic accuracy. In addition, the diagnostic reliability may only be limited to PPNs equal to or larger than 1 cm.

Preoperative localization of pulmonary nodules by electromagnetic navigation bronchoscopy combined with methylene blue injection.

Background: Electromagnetic navigation bronchoscopy (ENB) can help to accurately locate pulmonary nodules using a minimally invasive approach. This study sought to evaluate the clinical efficacy and safety of dye marking localization under the guidance of ENB followed by surgery. Methods: A retrospective analysis was performed of 61 patients who underwent ENB localization using methylene blue dye marking before surgery at Shanghai General Hospital from October 2021 to February 2022. The clinical efficacy and safety of ENB localization and the related factors affecting the navigation time of ENB location were analyzed. Results: ENB was performed on 170 pulmonary nodules in 61 patients with a median age of 60 [interquartile range (IQR), 18] years. The majority of patients (70.69%) had more than two pulmonary nodules. The median maximum nodule diameter was 10 (IQR, 8) mm, and 48.21% of the nodules were mixed ground-glass nodules. Median time for ENB navigation was 10.5 (IQR, 6) min. The navigation success rate was 92.96%, and the ENB location success rate was 95.89%. The rate of complications related to ENB localization was 1.64% (there was only one case of pulmonary hemorrhage). The multivariate analysis showed that the factors related to the navigation time included the node location (P=0.001) and location mode (P=0.04). Conclusions: ENB-guided methylene blue injection is an effective and safe tool for localizing and marking pulmonary nodules, and can be used to assist the diagnosis and treatment of early lung cancer. The node location and location mode had significant effects on navigation time.

Effect of the mycotoxins enniatin B and deoxynivalenol on the wheat aphid Sitobion avenae and on the predatory lacewing Chrysoperla carnea.

BACKGROUND: Fusarium species are responsible for Fusarium head blight (FHB) in wheat, resulting in yield losses and mycotoxin contamination. Deoxynivalenol (DON) and enniatins (ENNs) are common mycotoxins produced by Fusarium, affecting plant, animal and human health. Although DON's effects have been widely studied, limited research has explored the impact of ENNs on insects. This study examines the influence of DON and enniatin B (ENB), both singularly and in combination, on the wheat aphid Sitobion avenae and one of its predators, the lacewing Chrysoperla carnea. RESULTS: When exposed to DON (100 mg L-1) or DON + ENB (100 mg L-1), S. avenae exhibited significantly increased mortality compared to the negative control. ENB (100 mg L-1) had no significant effect on aphid mortality. DON-treated aphids showed increasing mortality from 48 to 96 h. A dose-response relationship with DON revealed significant cumulative mortality starting at 25 mg L-1. By contrast, C. carnea larvae exposed to mycotoxins via cuticular application did not show significant differences in mortality when mycotoxins were dissolved in water but exhibited increased mortality with acetone-solubilized DON + ENB (100 mg L-1). Feeding C. carnea with aphids exposed to mycotoxins (indirect exposure) did not impact their survival or predatory activity. Additionally, the impact of mycotoxins on C. carnea was observed only with acetone-solubilized DON + ENB. CONCLUSIONS: These findings shed light on the complex interactions involving mycotoxins, aphids and their predators, offering valuable insights for integrated pest management strategies. Further research should explore broader ecological consequences of mycotoxin contamination in agroecosystems. © 2024 Society of Chemical Industry.

Comparison of safety and anxiety/depression in computed tomography-guided hook-wire localization versus electromagnetic navigation bronchoscopy-guided localization: a retrospective cohort study.

Background: The utilization of computed tomography (CT)-guided localization and electromagnetic navigation bronchoscopy (ENB)-guided localization has gained significant traction in the localization of pulmonary nodules before video-assisted thoracoscopic surgery (VATS). This study aimed to ascertain the precision and safety of the two groups in the preoperative resection of isolated nodules in small peripheral lungs. Furthermore, we examined the subsequent outcomes pertaining to the decline in lung function and alterations in anxiety and depression following resection utilizing both localization techniques. Methods: A total of 177 patients with small-sized pulmonary nodules, scheduled to undergo video-assisted thoracoscopic limited resection, were enrolled in this study. The study involved the examination and comparison of pertinent findings obtained through the utilization of CT-guided hook-wire or ENB injection techniques. Results: The nodules were localized by ENB in 57 patients and by CT guidance in 120 patients. There were no significant complications in ENB-guided localization group (0/57). CT-guided hook-wire localization group had more complications (61/120, P<0.001). There was no disparity observed in pulmonary function decline 3 months post-operation between the two cohorts. The analysis of postoperative Hospital Anxiety and Depression Scale (HADS) scores indicated that the CT-guided localization group exhibited higher anxiety and depression scores on the initial day and 2 weeks following surgery. Conclusions: ENB-guided and CT-guided localization can effectively identify solitary pulmonary nodules. ENB-guided localization has fewer complications, lower incidence of adverse events, and less impact on postoperative anxiety or depression, suggesting that this is a promising, safe, and feasible method for localization of solitary pulmonary nodules.

Intraoperative marking of pulmonary nodules in a hybrid operating room: electromagnetic navigation bronchoscopy versus percutaneous marking.

Background: Intraoperative identification of subsolid or small pulmonary nodules during minimally invasive procedures is challenging. Recent localization techniques show varying success and complications. Hybrid operating rooms (HORs), equipped with radiological tools, facilitate intraoperative imaging. This study compares the accuracy and safety of marking pulmonary nodules using electromagnetic navigation bronchoscopy (ENB) combined with Cone Beam Computed Tomography (CBCT) vs. CBCT-guided percutaneous marking (PM). Methods: This retrospective cohort study included patients with pulmonary nodules scheduled for minimally invasive resection in a HOR. Marking techniques included ENB assisted by CBCT and PM guided by CBCT. The study compared the success rate, procedure time, intraoperative complications and radiation dose of both techniques. Results: A total of 104 patients with 114 nodules were included (October 2021-July 2024). Thirty nodules were marked using ENB, and 84 with PM. One case used both techniques due to ENB failure. No differences among groups were found in nodule characteristics. Success rates were similar (93.3% in ENB group vs. 91.7% in PM group, p = 1). Marking took significantly longer time in the ENB group (median 40 min) compared to PM group (25 min, p = 0.007). Five (6%) patients in the PM group experienced intraoperative complications compared to none in the ENB (p = 0.323). Radiation dose was significantly higher in the ENB group (p = 0.002). Conclusions: ENB assisted by CBCT is a safe and effective technique, with success rates comparable to CBCT-guided PM, though it may result in longer procedural times and higher radiation doses.

Intraprocedural computed tomography-guided navigation with ventilatory strategy for atelectasis (ICNVA): a modified electromagnetic navigation bronchoscopy.

Background: Computed tomography (CT)-body divergence limits the accuracy of electromagnetic navigation bronchoscopy (ENB) in peripheral lung lesions diagnosis. We developed intraprocedural CT-guided navigation with ventilatory strategy for atelectasis (ICNVA) ENB for patients with peripheral lung lesions. Methods: Retrospective observational study in which ten consecutive patients with pulmonary lesions (without bronchial direct connection) underwent ICNVA-ENB was conducted. During ICNVA-ENB, intraoperative CT data were used for ENB path planning, and a new ventilation strategy were employed to help maintain the pulmonary region in a static and inflation state which reduce CT to body divergence. We collected three sets of CT data: preENB CT, post-anesthesia intubation CT, and postENB CT. To evaluate the accuracy of ICNVA-ENB, we measured the distance between the ENB probe and the actual lesion location, but also recorded the results of rapid on-site evaluation (ROSE), and postoperative pathology. To evaluate the impact of CT-body divergence induced by atelectasis, we calculated the mutual position distance of target lesions in preENB CT, post-anesthesia intubation CT and postENB CT. Furthermore, ENB operation time and operative complications were recorded. Results: Our analysis revealed that the distance between the navigation probe with the actual location of lesion center was 4-10 (5.90±1.73) mm. The ROSE results were consistent with the postoperative pathological diagnosis in 9 out of 10 patients (90%). The ICNVA-ENB atelectasis CT-body divergence was smaller than traditional ENB (12.10±3.67 vs. 6.60±2.59 mm, P<0.01). The ENB operation time was 20-53 (29.30±10.14) minutes and one patient developed slight intrapulmonary hemorrhage. Conclusions: ICNVA-ENB can reduce the CT-body divergence and appears to be safe and accurate for patients with peripheral lung lesions.

Electromagnetic navigation bronchoscopy transbronchial lung nodule ablation with IllumisiteTM platform corrects CT-to-body divergence with tomosynthesis and improves ablation workflow: a case report.

Background: Transbronchial ablation of lung nodules is gaining popularity as part of lung-preserving strategy for patients with multifocal lung cancers or multiple lung oligometastases. Accuracy in placement of ablation catheter is of utmost importance in order to achieve adequate ablation margin. However, older systems are not precise enough for confident placement of ablation catheter and often require multiple cone-beam CT (CBCT) to confirm and readjust its position. The following case is the first microwave lung ablation utilizing the novel IllumisiteTM platform (Medtronic, Minneapolis, MN, USA) in the hybrid operating room (HOR), with enhanced accuracy and workflow. Case Description: A 66-year-old lady had multiple resected adenocarcinomas in bilateral lungs. Upon CT monitoring a right middle lobe (RML) ground glass opacity with solid centre was found to be suspicious due to increasing size and density. Transbronchial electromagnetic navigation bronchoscopy (ENB) microwave ablation of the lesion was performed as part of lung-conserving strategy. After initial navigation, the adjusted nodule position provided by the IllumisiteTM platform after correcting the CT-to-body divergence prompted operators to renavigate and readjust the position of the locatable guide (LG) swiftly to gain accurate access to the nodule, which was confirmed by CBCT. Positional data at the tip of extended working channel (EWC) also allowed precise placement of needle for subsequent ablation. Conclusions: IllumisiteTM is a novel electromagnetic navigational platform that corrects for CT-to-body divergence and ensures continuous locational information by an additional positional coil in the tip of EWC. This precision is especially important for the placement of ablation catheter, as slight deviation would lead to insufficient ablation margin and future recurrence. Workflow is improved by reducing the number of CBCT required for instrument position adjustment.

Utility and safety of sole electromagnetic navigation bronchoscopy under moderate sedation for lung cancer diagnosis.

Background: Electromagnetic navigation bronchoscopy (ENB) is an emerging technique for diagnosing pulmonary lesions. However, limited data is available on its sole utility under a least invasive setting without general anesthesia. We aimed to evaluate the diagnostic performance and safety of sole ENB under moderate sedation for diagnosing pulmonary lesions suspicious for lung cancer and to determine clinical factors associated with a better diagnostic yield. Methods: We performed a retrospective analysis of consecutive patients who underwent sole ENB under moderate sedation for lung lesion biopsy between August 2016 and June 2021 at Seoul National University Bundang Hospital, a tertiary center in South Korea. Diagnostic yield of the ENB-guided biopsy, safety endpoints defined by the incidence and severity of associated complications, and factors associated with higher diagnostic yield were evaluated. Results: A total of 94 patients were evaluated. The final diagnostic yield of ENB was 81.5% (75/92), excluding two indeterminate cases. The diagnostic yield ranged from 79.8% to 81.9% assuming all indeterminate cases were false-negatives (79.8%) and true-negatives (81.9%). The sensitivity and specificity for malignancy were 77.6% (ranging from 75.6% to 77.6%) and 100%, respectively. Any-grade pneumothorax occurred in 4.3% of the patients, and 2.1% developed pneumothorax requiring additional intervention. Multivariable analyses identified the presence of a class 2 bronchus sign as the only significant predictor for a higher diagnostic yield (odds ratio =4.83, 95% CI: 1.16-20.12). The diagnostic yield of ENB among those with class 2 bronchus sign was 89.8% (53/59). Conclusions: Sole ENB under moderate sedation for diagnosing pulmonary lesions displayed a good diagnostic yield and safety profile, thus confirming its utility in a least-invasive setting. Moreover, sole ENB could be possibly be superior to transthoracic needle aspiration for diagnosing lesions with class 2 bronchus sign accounting for similar yields and lower complication rates.

Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study.

Objective: To determine whether CT-to-body divergence can be overcome to improve the diagnostic yield of peripheral pulmonary nodules with the combination of shape-sensing robotic-assisted bronchoscopy (SSRAB) and portable 3-dimensional (3D) imaging. Patients and Methods: A single-center, prospective, pilot study was conducted from February 9, 2021, to August 4, 2021, to evaluate the combined use of SSRAB and portable 3D imaging to visualize tool-in-lesion as a correlate to diagnostic yield. Results: Thirty lesions were subjected to biopsy in 17 men (56.7%) and 13 women (43.3%). The median lesion size was 17.5 mm (range, 10-30 mm), with the median airway generation of 7 and the median distance from pleura of 14.9 mm. Most lesions were in the upper lobes (18, 60.0%). Tool-in-lesion was visualized at the time of the procedure in 29 lesions (96.7%). On the basis of histopathologic review, 22 (73.3%) nodules were malignant and 6 (20.0%) were benign. Two (6.7%) specimens were suggestive of inflammation, and the patients elected observation. The mean number of spins was 2.5 (±1.6) with a mean fluoroscopy time of 8.7 min and a mean dose area product of 50.3 Gy cm2 (±32.0 Gy cm2). There were no episodes of bleeding or pneumothorax. The diagnostic yield was 93.3%. Conclusion: This pilot study shows that the combination of mobile 3D imaging and SSRAB of pulmonary nodules appears to be safe and feasible. In conjunction with appropriate anesthetic pathways, nodule motion and divergence can be overcome in most patients. Trial Registration: https://clinicaltrials.gov Identifier NCT04740047.

Electromagnetic navigational bronchoscopy-guided dye marking to identify the subsegmental bronchus in thoracoscopic anatomic subsegmentectomy.

Video-assisted thoracoscopic surgery (VATS) subsegmentectomy has been widely used to resect small-sized lung lesions in clinical practice. Precise identification of the subsegmental bronchus is one of the essential steps in performing thoracoscopic anatomic subsegmentectomy. Here, we report a thoracoscopic right S2 a segmentectomy with preoperative electromagnetic navigational bronchoscopy (ENB)-guided injection of methylene blue to identify the subsegmental bronchus in a 51-year-old male. We successfully performed complicated surgery using this method. This ENB-guided dye marking method may accurately distinguish the subsegmental bronchus to effectively guide surgery.

Electromagnetic navigation-guided preoperative localization: the learning curve analysis.

BACKGROUND: The electromagnetic navigation bronchoscopy (ENB) was increasingly used to mark small pulmonary nodules (PNs) for video-assisted thoracic surgery (VATS) resection due to high effectiveness and low risk. However, no study reports the learning curve of ENB-guided preoperative localization. In the study, we aimed to describe the learning curve of ENB-guided preoperative PNs localization initially. METHODS: Consecutive PNs cases that underwent ENB localizations between October 2018 and October 2019 by the same surgeon in our center were included in the study. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB localization. RESULTS: A total of 89 ENB localization from 64 patients were included in this study. The learning curve was divided into 3 phases: Phase I (the initial 11 cases), Phase II (the 12th to the 47th cases), and Phase III (the 47th to the 89th cases). The success rate of ENB localization has increased with the accumulation of operational experience in 3 phases (72.73%, 91.67%, and 97.62%, P=0.049). The distance from the ENB guide wire tip to the center of the lesion in Phase I was significantly longer than those in Phase II and Phase III (2.46±1.76 vs. 1.36±0.94 and 1.47±0.97 cm, P=0.014 and 0.027, respectively). Sex, bronchus sign, and learning curve phase were independent risk factors influencing operative time (OT) (OR =8.187, 18.847, and 13.920, respectively). CONCLUSIONS: The technical competency, which is indicated by higher success rate, localization accuracy, and shorter OT, for ENB-guided preoperative PNs localization was achieved at the 47th operation.

Application of Electromagnetic Navigation Bronchoscopy in the early diagnosis and treatment of lung cancer: a narrative review.

The diagnosis of lung cancer has long been a problem facing clinicians worldwide, and the emergence of electromagnetic navigation bronchoscopy (ENB) has played a critical role in the early diagnosis of lung cancer. Compared with other types of biopsy techniques (e.g., transthoracic needle biopsy, bronchoscopy, thoracoscopic biopsy, and thoracotomy), ENB guarantees high diagnostic accuracy and safety. In recent years, with the continuous development of ENB technology, the scope of its epitaxy has also expanded. This technology is no longer a simple auxiliary diagnosis test but an innovative technology that simultaneously assists in surgical treatment, opening new avenues of research for the treatment of early-stage lung cancer. However, ENB, as a human-mediated operating system, has some limitations and uncertainties in its actual clinical application and promotion, which need to be addressed as we continue to develop ENB technology. In response to the bottleneck in developing ENB technology in current clinical diagnosis and treatment, relevant scientific research and development personnel and clinicians have also performed continuing exploration and improvement of methods. However, to completely overcome the limitations of ENB, more technological innovations are needed. In this review, we describe the current major clinical application directions, application advantages, and limitations of ENB.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection.

BACKGROUND: Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions. METHODS: From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions. RESULTS: Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported. CONCLUSIONS: ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Electromagnetic bronchoscopy guided microwave ablation for early stage lung cancer presenting as ground glass nodule.

BACKGROUND: Patients with early-stage lung cancer are sometimes medically inoperable, and for patients with multiple primary lung cancers, surgical resection alone sometimes proves to be impractical. Local treatments like microwave ablation (MWA) are investigational alternatives for these patients. Most reported MWA procedures for lung cancers are performed percutaneously under CT guidance. MWA navigated by electromagnetic bronchoscopy (ENB) has been limitedly studied. In this study, we aimed to evaluate the safety and feasibility of MWA under ENB guidance in patients with inoperable early-stage lung cancers or multiple primary lung cancers which cannot be completely resected. METHODS: From June 2019 to December 2020, preliminary attempts of ENB-guided MWA were made in five medically inoperable patients with a single early-stage lung cancer and ten patients with multiple primary lung cancers which were difficult to resect at the same time. For patients with concomitant pulmonary nodules which needed surgical resection, thoracoscopic resections were performed following ENB-guided MWA. The safety, feasibility, and technique effectiveness of treatments were evaluated. RESULTS: ENB-guided MWA for 15 ground glass nodules (GGNs) in 15 patients was completed in accordance with the planned protocol. Biopsy of 13 GGNs showed malignancy. Five patients received simple ENB-guided MWA without simultaneous surgical resection and ten patients received simultaneous surgical resection for 13 concomitant pulmonary nodules. CT scan by the first postoperative week showed technique effectiveness of ablation for 11 nodules indicated for MWA. Four patients had mild complications after the procedure and recovered shortly after treatment. CONCLUSIONS: For medically inoperable patients with a single GGN manifesting early-stage lung cancer and patients with multiple primary early-stage lung cancers which cannot be resected at the same time, ENB-guided MWA might be a safe and feasible alternative local treatment, whether combined with surgical resection or not. However, large, prospective, randomized, multicenter studies are needed to confirm its role in the treatment of early-stage lung cancer.

[68Ga]-DOTATATE PET/CT and PET/MRI in the diagnosis and management of esthesioneuroblastoma: illustrative cases.

BACKGROUND: Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare sinonasal neuroectodermal malignancy with a slow onset of symptoms, favorable 5-year survival, and a propensity for delayed locoregional recurrence. Current treatment options include resection, adjuvant radiotherapy, and/or chemotherapy; however, because of its rarity and location, determining the optimal treatment for ENB has been challenging. OBSERVATIONS: ENBs strongly express somatostatin receptors (SSTRs), particularly SSTR2, providing a molecular target for imaging and therapy. LESSONs: The authors present a case series of ENBs imaged with [68Ga]-DOTATATE PET/MRI and PET/CT and discuss the emerging role of [68Ga]-DOTATATE PET for ENB diagnosis, staging, and treatment response monitoring.

Electromagnetic navigation bronchoscopy as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway: an initial retrospective single centre series.

BACKGROUND: The performance of electromagnetic navigation bronchoscopy (ENB) is reported with substantial variation, which may question its clinical usefulness. However, ENB may hold its true value when used as an additional minimal invasive diagnostic option before potential surgery in selected diagnostically challenging patients where traditional diagnostic methods have failed. We evaluated the safety and performance of ENB when used as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway (DLCDP) and its ability to reduce surgical diagnostic procedures. METHODS: A retrospective study was performed on eighty-two consecutive patients at Odense University Hospital from June 2016 to March 2018 with diagnostically challenging pulmonary lesions referred for ENB as an adjunct diagnostic procedure under the DLCDP. Patients with benign or inconclusive ENB pathology were either referred for further biopsies, surgery or repeated computer tomography (CT) scans for surveillance purposes. RESULTS: Eighty-one ENB procedures were performed in 80 patients. In 87.7% of the cases previous diagnostic methods had been unsuccessful. The mean target diameter was 1.55 cm and the average follow-up duration was 11 months. The diagnostic accuracy was 75%, while the diagnostic yield/sensitivity, negative predictive value and negative likelihood ratio was 51%, 67% and 0.49, respectively. No pneumothoraces and only one intrapulmonary haemorrhage was recorded, which was managed conservatively. The learning curve revealed an increase in diagnostic accuracy from 67.5% to 82.9% when comparing the first 40 ENB procedures with the last 41 procedures, however, this was not statistically significant (p-value: 0.11). CONCLUSIONS: ENB was found to be a safe procedure with an acceptable diagnostic accuracy and yield in highly selected diagnostically challenging patients. The introduction of ENB carried a notable learning curve but proved to be a valuable adjunct diagnostic option in the DLCDP, which may help to reduce the number of potentially unnecessary or harmful surgical procedures in frail patients.

Cognitive Load in Electromagnetic Navigational and Robotic Bronchoscopy for Pulmonary Nodules.

Background: Electromagnetic navigational bronchoscopy (ENB) and robotic-assisted bronchoscopy (RB) require a high degree of decision-making and psychomotor skill. Cognitive load theory is the overall effort expended by individuals in response to a task and is closely related to the usability of devices for medical procedures. High cognitive workload leads to poor surgical outcomes and represents a bottleneck for learning that affects performance.Objective: To analyze the cognitive load associated with ENB and RB in experienced ENB practitioners learning RB.Methods: Six experienced ENB bronchoscopists performed ENB and RB on a human cadaver model of peripheral pulmonary nodules. To assess cognitive load, we used the Surgery Task Load Index (SURG-TLX) and biometric changes. The SURG-TLX questionnaire was given to the provider after every peripheral pulmonary nodule biopsy with ENB and RB. Pupillary dilation and screen changes were continuously measured throughout the procedure for each biopsy attempt to collect biometric measures of cognitive load. Procedural time and biopsy outcome were also recorded.Results: Forty procedures (ENB and RB) were analyzed. Task complexity (23%) and mental demand (21.4%) were the highest contributors to cognitive load in ENB and RB. The cumulative SURG-TLX was significantly lower for the RB (69.25 vs. 101.25; P < 0.01). Total procedure time was greater for ENB (6.7 min; SD 1.5) compared with RB (4.4 min; SD 1.5; P = 0.01). Pupillary diameter was similar across the modalities (RB vs. ENB), but the diameter was higher during the biopsy portion (4.25 mm) than the navigation portion (4.01 mm).Conclusion: The intrinsic cognitive load of RB was highly manageable by existing ENB practitioners, and in this study, RB appeared to be less mentally demanding. Future development and training should focus on task complexity and mental demand for RB. The biopsy portion, regardless of bronchoscopic modality, should be a focus for education and training.