Diagnostic Yield

Monarch RAB

Chaddha et al. [11], in a multi-center retrospective study of 167 lesions (71% were in the outer third of the lung), 165 patients were included in the analysis, with an average follow-up of 185 ± 55 days. The average size of target lesions was 25.0 ± 15.0 mm. An excellent safety pro le was demonstrated where pneumothorax and airway bleeding occurred in 3.6 and 2.4% cases, respectively. Reaching the target was successful in 88.6% of cases, and biopsies were successfully obtained in 98.8%. The diagnostic yield estimates­

ranged between 69.1% and 77%, assuming the cases of biopsy-proven infammation without any follow-up information (N = 13) were non-­ diagnostic and diagnostic, respectively. The yield was 81.5, 71.7, and 26.9% for concentric, eccentric, and absent r-EBUS views, respectively. Diagnostic yield was not affected by lesion size, density, lobar location, or centrality.

The study concluded that RAB implementation in community and academic centers is safe and feasible, with an initial diagnostic yield of 69.1–77% in patients with lung lesions that require diagnostic bronchoscopy. It is important to mention that diagnostic yield in this study was de ned as the percentage of procedures yielding a diagnosis based on nal pathology.

In the rst prospective, multi-center study (The BENEFIT study) of total 54 patients, Chen et al. [7] demonstrated a very high lesion localization rate of 96.2% of peripheral lesions with a median diameter of 23 mm. Bronchus sign was present in 59.3%, R-EBUS was utilized, and diagnostic yield was 74.1%. Pneumothorax was reported in 2 of 54 cases (3.7%); tube thoracostomy was required in 1 of the cases (1.9%). No additional adverse events occurred.

Ion Endoluminal Robotic System

Feilding et al. were the rst to use it in humans, as mentioned earlier in 29 patients with a mean lesion size of 14 mm diameter roughly and bron-

chus sign present in 58.6%. The diagnostic yield in his study was 88%. The same diagnostic yield was re-demonstrated in three other studies. Benn et al. [14] combined robotic bronchoscopy with cone-beam CT for secondary con rmation in 52 patients with predominantly upper lobe solid nodules with diameter less than 2 cm. The main objective was to determine the overall diagnostic accuracy of the technique and sensitivity of malignancy. Bronchus sign was present in 46% of the patients. An 84% procedural sensitivity for malignancy and an overall 86% diagnostic yield were achieved when all biopsy results and fol- low-­up imaging were included in the analysis. The study concluded that combining RAB with cone beam CT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies.

Another publication of the shape-sensing technology of RAB in 2021 by Kalchiem-Dekel et al. [12] evaluated the feasibility, diagnostic yield, and determinants and found an overall diagnostic yield of 81.7%. A total of 159 pulmonary lesions were targeted with a median lesion size of 1.8 cm (1.3–2.7 cm) and bronchus sign present in 62.9%. Two-thirds of the lesion were located beyond the sixth-generation airway. Lesions at or larger than 1.8 cm had a much higher diagnostic yield, concluding that lesion size remains a major predictor of the diagnostic procedure. The overall complication rate was 3.0%, and the pneumothorax rate was 1.5%.

Ost et al. in a prospective multi-center analysis of shape-sensing robotic-assisted bronchoscopy for the biopsy of pulmonary nodules (The PRECISE study) published preliminary results of 155 enrolled patients with a mean nodule diameter of 17 mm where 69% located in the upper lobes and bronchus sign only present in 25% of cases. Diagnostic yield was 82% for nodules at or less than 20 mm and 85% for nodules >20 mm. One asymptomatic pneumothorax was reported, and no chest tube placement was needed (Table 26.1).

Therapeutic Robotic-Assisted

Bronchoscopy

The current literature is encouraging that RAB can reach further in the lung periphery with a steady, stable scope position. In real-time, combined with 3D fuoroscopy or cone-beam CT, a diagnosis of the target lesion can be made. This approach opens the door for ablative therapies like microwave probes, LASER, photodynamic therapy, and cryoablation and to the delivery of certain therapeutics in non-operable patients when appropriate. Studies are still needed to ensure feasibility, safety, and document outcomes.

Summary

Despite the advances in innovation and early data suggesting a role for the use of robotic bronchoscopy in peripheral lesions, the adoption of this platform is still in its infancy. As with any new technology, many logistical limitations prevent the widespread adaptation of robotic bronchoscopy in current times. First and foremost, the equipment cost may be prohibitive in early adap-

tation until a clear advantage in yield, a decreased need for additional procedures, or a shorter procedure time is apparent. The complexity of equipment set-up in operating rooms and bronchoscopy suites, as well as training of clinicians as well as ancillary staff all follow a steep learning curve, which further slows down the adoption process. Larger prospective studies are needed to explore the utility and ef cacy of RB for peripheral lesions in the future.

These platforms may also guide the way to peripheral lesions with superior stability to deliver ablative therapies for inoperable peripheral lung tumors, such as photodynamic therapy, LASER, radiofrequency ablation, cryoablation, and microwave ablation. Further combination of RAB with cone-beam CT may increase the already higher precision offered by RAB, although this is still to be studied and applied in routine clinical practice.

References

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4.\Eberhardt R, et al. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36–41.

5.\Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-­ analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385–93.

6.\Folch EE, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: one-year results of the prospective, Multicenter NAVIGATE Study. J Thorac Oncol. 2019;14(3):445–58.

7.\Chen AC, et al. Robotic bronchoscopy for peripheral pulmonary lesions: a multicenter pilot and feasibility study (BENEFIT). Chest. 2021;159(2):845–52.

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Introduction and De nition of the Procedure

Mediastinoscopy is a surgical procedure that allows the inspection and the palpation of the upper mediastinum as well as the taking of biopsies of lymph nodes, tumours or any other tissue within the range of the exploration. For lung cancer staging, the range of exploration includes the cervical lymph nodes of the sternal notch; the lymph nodes along the trachea and both main bronchi, that is, the superior and inferior, left and right, paratracheal lymph nodes; the subcarinal nodes and the right and left hilar lymph nodes, according to the International Association for the Study of Lung Cancer (IASLC) lymph node map [1]. Inspection and palpation of the upper mediastinum are essential to identify the lymph nodes,

R. Rami-Porta (*)

Thoracic Surgery Service, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain

Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES), Lung Cancer Group, Terrassa, Spain

S. Call

Thoracic Surgery Service, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain

Department of Morphological Sciences, Medical School, Autonomous University of Barcelona, Bellaterra, Spain

see their aspect and feel their consistency and degree of attachment to mediastinal structures, as well as to differentiate between mere contact and tumour invasion of the mediastinum. The removal or the taking of biopsies of lymph nodes is performed under direct vision, and these specimens allow the pathologist to examine the status of the nodal capsule and the involvement of the extranodal tissues that are criteria of incomplete resection [2].

History and Historical Perspective

When Eric Carlens described the technical details of mediastinoscopy and reported six exemplary cases in 1959, he had already performed more than 100 procedures without complications [3]. Mediastinoscopy was the culmination of a series of procedures developed to diagnose intrathoracic diseases without relying on thoracotomy. As early as 1942, Albanese, from Buenos Aires, Argentina, described an incision over the sternocleidomastoid muscle to explore and biopsy the paratracheal and the para-oesophageal lymph nodes [4]. Seven years later, in 1949, Daniels described the biopsy of the scalene fat pad through a small supraclavicular incision. This biopsy allowed the diagnosis and staging of lung, digestive and gynaecological cancers and the diagnosis of intrathoracic in ammations and infections, such as sarcoidosis and tuberculosis,