Robotic Bronchoscopy Roundtable, Part 2: What is “Advanced Imaging?”
In this video, Jaspal Singh, MD, MHA, MHS, moderates a roundtable discussion with Bradley L. Icard, DO, Brian Shaller, MD, and Dominique Pepper, MD, MBChB, MHSc on the impact of advanced imaging on robotic bronchoscopy. The participants also describe advanced imaging, how its precision helps clinicians make accurate diagnoses, its impact on patient care, and more. This is part two of a three-part series.
For Part 1 of this 3-part series, click here.
For Part 3 of this 3-part series, click here.
Additional Resources:
- Agrawal A, Hogarth DK, Murgu S. Robotic bronchoscopy for pulmonary lesions: a review of existing technologies and clinical data. J Thorac Dis. 2020 Jun;12(6):3279-3286. doi: 10.21037/jtd.2020.03.35. PMID: 32642251; PMCID: PMC7330790.
- Kent AJ, Byrnes KA, Chang SH. State of the Art: Robotic Bronchoscopy. Semin Thorac Cardiovasc Surg. 2020;32(4):1030-1035. doi:10.1053/j.semtcvs.2020.08.008
- Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest. 2021;159(2):845-852. doi:10.1016/j.chest.2020.08.2047
TRANSCRIPTION:
Jaspal Singh, MD, MHA, MHS: Welcome back everybody. I'm Dr. Jaspal Singh. Again, on behalf of Consultant360, this is our robotic bronchoscopy roundtable series. This is going to be part two. So, in part one, just to review, we had Dr. Bradley Icard, Dr. Dominic Pepper and Dr. Brian Shaller all give us a little bit of an insight about robotic bronchoscopy and what it means for our patients, our population and what the technological innovation has really been doing transformative things to become the first and best choice for many of our patients who are undergoing lung biopsies.
So with that, welcome to all three of you again. I'm going to have you all introduce yourselves, and we're going to talk a little bit more about imaging. So Dr. Shaller, introduce yourself.
Brian Shaller, MD: Hi, my name is Brian Shaller and I'm an interventional pulmonologist at Stanford University in California.
Dr Singh: Great, Dominic.
Dominique Pepper, MD, MBChB, MHSc: Thanks for having me. My name is Dominic Pepper, located in Olympia, Washington. I'm an advanced bronchoscopist.
Dr Singh: Great, and Brad?
Bradley L. Icard, DO: Nice to meet everybody. I'm Bradley Icard. I am an advanced bronchoscopist at Cone Health in Greensboro, North Carolina.
Dr Singh: Fantastic. So, we've talked a lot about robotic bronchoscopy, and Brian, I'm going to ask you a little bit about what is this whole idea of advanced imaging? I thought the system kind of when I'm picturing a robotic is kind of driving you there, you know where you're at, you know what you're getting, walk me through this whole aspect of where this is and what the field is going through.
Dr Shaller: Yeah, that's a great question. So we should start with navigational bronchoscopy, which is really the sort of general umbrella under which robotic bronchoscopy platforms exist. Since these technologies were developed in the mid 2000s and developed over into the realm of bronchoscopy, they've all relied on historical imaging. So, a patient's pre-procedure CT scan, to provide navigational guidance to the procedure list and help tell them what airways to go down, how far to go, where to turn, etc. The problem is that the conditions under which a CT scan are performed are very different from the conditions under which a bronchoscopy is performed and so invariably the nodule that you're driving out to moves a little bit.
The lung moves, the lung breathes, the patient moves and so where you think you are and where you actually are might not be the same thing and while this might not matter if you're a few centimeters off from a very large lung mass, you can imagine that if you're going after increasingly smaller nodules, those little bits of divergence in where you think you are and where you ought to be could make the difference between getting a diagnosis and not getting a diagnosis.
So advanced imaging is a term that we use to basically describe any kind of additional imaging modality, whether it's special fluoroscopy, augmented fluoroscopy, digital tomosynthesis, which is a way to use fluoroscopy to get semi three dimensional images all the way up to intraprocedural CT scanners so that we can drive out to a nodule and then actually get real-time visual information about where we are and how well we're doing on our navigation.
Dr Singh: Now that's great. So you're basically taking me way back, way back a little bit. I'm going to date myself for 2D fluoroscopy. We're basically, we think we're in an area, we don't even know, and for certain patients, the diaphragm comes up pretty high, you can't even see where you are. And now you're talking about almost essentially doing a CT-guided bronchoscopic biopsy, very small lesions with incredible precision. And that's really fascinating. So it sounds pretty space-age, technical, very expensive.
So Dominic, walk me through this a little bit. Is that, am I overthinking it or what are you seeing in your space?
Dr Pepper: Well, we started off with robotic bronchoscopy, and I think at one time it flashed in my head, you know, we may never need advanced imaging. We're just going to be doing robotic bronchoscopy and get everything because our yields went up so much, we're able to get patients answers.
And then you miss a couple of diagnoses and then you realize I'm only getting 80% or 82% of what I would like to get. And then speaking to other folks, they’re using advanced imaging, and you realize that the radiologists have a benefit of being able to see their needle or their tool go into the nodule and get that sample. And you start reading case reports, papers, showing folks are getting much better diagnostic yield, and they're going for more tougher lung nodules.
And that's kind of what we want to do. We want to go for stuff that's less than 10 millimeters in size that's in the periphery so that we can get that early-stage lung cancer and benefit the patient.
So despite for a year and not using advanced imaging, we switched over to a mobile comb beam CT and after using it, we haven't looked back. The ability to combine both robotic bronchoscopy with advanced imaging has been a game changer.
Dr Singh: That's just fascinating. And Brad, I was wondering what your experience has been like.
Dr Icard: Yeah, I would have to echo the same sentiments. You know with the addition of advanced imaging, I think there's two things for me that really play: the safety profile that changes for the patient as well as the efficiency, so when you are going after some of these really small lesions, before we would maybe second guess ourselves on should we go after something that's sitting on the crown of the diaphragm? Should we go after something that's sitting on the aortic knob, you know, some very tricky locations or even consideration for something within The station six location, you know in front of the aorta, you know with advanced imaging We're now able to get into the space confirm where the location is feel Confident that we're able to pass a needle or pass something sharp for the biopsy into a space that decreases the risk, even something simple from cases recently ensuring that you're not crossing the minor fissure line on the right side. So, these are all things that help prevent pneumothorax, prevent bleeding complications, and at the same time increase the diagnostic yield. And the second thing is efficiency.
If you have multiple cases to get done in the day and you rely solely on the robotics platform to get to your location, I do believe with using a golf reference, it'll get you from a tee box to green side. But if you're trying to get into the hole per se, if you're going after smaller and smaller lesions, you really need to be able to understand the contour of where you are. You know, is that lesion, you know, close to the diaphragm? Is there a lot of motion? Is there atelectasis for example? These are all things that we try to do to help prevent what Brian said earlier regarding CT to body divergence.
And by helping to eliminate that increases your procedural efficiency so you can do more cases in a day.
Dr Shaller: One thing I would like that's, I agree with everything you both said. And I think one thing to add and that I like to keep in mind is that all of the technologies we're talking about whether it's older platforms of navigation to the brand-new robot, they were all validated using CT. And so all of these technologies have very important roles. And I think robotic bronchoscopy is-- I think it's here to stay. And I think it's revolutionized how we do our procedures.
But it was validated using combi MCT and advanced imaging. And so to take this new technology of the robot and use it alongside with the most state-of-the-art imaging is probably the best thing that you can do for your patients. and using the gold standard that all of our tools were tested and validated off of.
Dr Singh: No, I think that's great. So basically, what you're saying is, I'm just going to summarize this idea of advanced imaging. The idea is one thing to have a robotic bronchoscopy. And I think for a lot of our listeners and our audience today, that itself is a big leap that you've taken, you've gone from a, what was traditionally might be a CT-guided biopsy your surgical biopsy or radiologic surveillance, maybe attempt a bronchoscopy if you needed to. But in reality, now that's becoming the first and best choice for biopsy, but it's not sufficient because it introduces a lot of variables that potentially weren't unintentionally introduced, right? For example, the CT might happen a while ago, that person's body might change, the nodule might change, the target might have changed, the disease could have changed in the time and that short span, it could be a short span, it could be a long span between that time. So you need something real time that the tools that were currently available at our most popular, like two-dimensional fluoroscopy, are grossly limited in how much resolution you have, as well as how much of the chest they can really see, even with moving angles around.
That you need something additional to get a three-dimensional spatial understanding in real time of where you are, what that nodule, what the target looks like, and to see are you actually going to biopsy, especially as the demand for tinier nodules, tinier targets, as that increases, which is all pay, as we move that needle, we need to have more precision. And the point isn't just to sort of be fancy about this for my technological, technological perspective, but as Brad was saying, this is, these are patients, these are people, right? This is not just us showing off technology or acquiring cool tools. This is important about getting people at diagnosed at the earliest stage possible for chance of cure. Am I getting that right?
Dr Shaller: Absolutely.
Dr Icard: Absolutely. and one other thing I'd like to point out is that when we, when we start, I think all of us would say Dominic and Brian too, when we are evaluating the case for robotic bronchoscopy, to me it's location, location, location, similar to real estate, you're you're planning your case and thinking about that.
And for me included, I think about the patient and then even some simple things like body habitus and BMI, right? These are all things that play a huge role in the development of atolectasis, for example, once a patient gets put to sleep under general anesthesia. And so, you know, if there is a lesion that is in the periphery of the lung, and it's, you know, distal to the, I kind of use the thoracic spine cutoff, anything that's below that, there's, if their BMI is up and there's risk for adolescence or divergence, you know, we can position the patients now to help prevent that. And so as we learn more in this community and we continue to have multidisciplinary and collegial discussions like we have now.
We learn from each other about the development of this as a rapidly growing field. It's great to be part of that. That's great.
Dr Pepper: To go down what Brad said, I mean I was fortunate to go to a course where Brian was teaching and one of the words that they all said was once you see the picture, once you see what advanced imaging is showing you, you just can't unsee it. When you take the picture and you think, my robot catheter is at the virtual target, and then you take the picture and you realize, oh my gosh, I'm two centimeters away. And there's a paper that came out that showed in low lobes, does it take any divergence of two centimeters and upper lobes divergence of one centimeter? Once you see how close the robot got, but it's too far away for you to make a successful biopsy, once you see a picture like, I've got to have advanced imaging, if I'm going to walk back to my patient and tell them, I got the answer.
Dr Singh: You know, it's, that's a very good important point is if you still walk back to the patient and sort of look them in the eye and say, I just put you under general anesthesia for a complicated procedure. And I didn't do a complete job because I was limited. And I want you to have the best chance.
And I think it's sometimes all of Sometimes all of us kind of, sometimes it hits us hard, right? That we couldn't get an answer on someone, whereas this now increases the odds tremendously. So I think it's great. I think it's really cool what the field is showing and it's going in the space, but I think for our primary care audience, for others listening, just be patient with us.
Let us know that and be demanding, you know, that this is the kinds of things that we need to sort of see does the field is evolving quickly, and we are learning a ton, but we're providing a ton of value as this space evolves.