So, again, good afternoon, everybody. My talk today is on Overcoming CT to Body Divergence with Imaging. My name is Jennanie Reisenauer. I'm an interventional pulmonologist and thoracic surgeon at Mayo Clinic in Rochester. The purposes of this talk today is to describe CT to body divergence and its implications in robotic bronchoscopy, to discuss the available imaging adjuncts, to delve into the advantages and disadvantages of each imaging system, touch on the literature available, and have a little fun. We'll start with the first audience response question. This is just more of a survey. What imaging system currently exists in your hospital system for robotic bronchoscopy, if you're using robotic bronchoscopy at all, 2D fluoro, 3D fixed, 3D mobile, or any of the above in combination with body vision? We'll go to the next slide so that people can scan the QR code. So it looks like it's almost a half and half, oh. It was a half and half split and then one person probably voted, but now it's 50% 2D fluoro and 30% 3D mobile. So now we're gonna delve into questions that actually do have a right and a wrong answer, which of the following does not contribute to CT to body divergence? Is it registration, atelectasis, nodule motion during bronchoscopy, or lung resection in the patient that occurred about a year ago? Okay. Perfect, so most people said it's lung resection that happened a year ago, probably doesn't matter, and that's because most of the time, the CT you would imagine has been done more recently than a year ago. So it would have accounted for the fact that that patient has some anatomical changes. What is CT to body divergence? This is from Dr. Pritchett's paper. It's the difference between the static pre-procedural CT and the dynamic lung that's actively breathing in an awake patient during the bronchoscopic procedure. This can be attributed to the difference in the volume between the CT and real time. Nodule changes, which can happen either due to potential delay or if the patient is paralyzed, it has to do with the tidal volume, the PEEP. It has to do with registration and if there's any inaccuracies there. And then atelectasis, because many of us know it doesn't take that long before the lung becomes atelectatic, which will be covered in a subsequent section. So next question, true or false? Divergence is predominantly, majority confined only to the lower lobes. True or false? Awesome. Most people say false, so I can skip the next slide. This is a paper that we published in the Mayo Clinic Proceedings, where we actually measured catheter divergence during robotic bronchoscopy. And if you define divergence as either 10% overlap or greater than 10 millimeters, we found that almost 30%, if you call it 10% overlap, or up to 50% of divergence was seen even in the upper lobes. So there's significant amount of divergence that can occur in the upper lobes, not just the lower lobes. And it goes back to all the factors that we talked about in the previous slides. So just a quick overview of the different imaging systems that are out there. This is the standard 2D fluoroscope, which it looks like the majority of the audience has. This allows for a large field of view with rotation. It's compatible. It's portable. But it does not easily account for divergence. So this is a picture of the ion system, but there are adjuncts built into that system that allows you to help a little bit with those divergence issues. One of those is adjusting your LAO-REO rotation to the optimal fluoro angle so that the lesion is better seen under fluoroscopy. The other is radial EBIS. And then marking where you get the best radial EBIS signal, as denoted by the pink star, to try to make sure that you're biopsying in the same location that you got a radial EBIS signal. With adjuncts such as body vision, this is allowed for real-time intraoperative 3D imaging without the expense of an expensive 3D system. This uses fluoroscopic localization, which is attached to a board and correlates to the preoperative CT scan. There are some papers out there that have demonstrated a localization success rate of 96% with flexible bronchoscopy. And currently, this is being used in conjunction with robotic bronchoscopy, but large case series are still pending publication. Moving on to the fixed cone beam CT, this is a picture of the Siemens system, but also manufactured by Philips and GE. This combines fluoroscopy with real-time CT, and it allows you to have an overlay. So you can see that holographic augmented fluoroscopy to help guide your biopsies, and it prevents you having to spin every time you adjust your catheter or your needle. It allows you to verify tool and lesion and can overcome CT to body divergence, which has been cited and reported in the literature. Here's an example of a pre-procedural CT on the left. And on the right is where we're using robotic bronchoscopy to die mark the lesion and subsequently excise it. I love this picture because it shows not only the imaging quality of the cone beam system, but also the stability and the reach of modern day robotic bronchoscopes. We use this equipment all the time in our fixed cone beam room to do single anesthetic, biopsy staging, and resection events with significant success. And the cone beam CT here has really been a key player in being able to offer that to patients. In terms of the effective dose for lung imaging, this paper looked at how much radiation a patient incurs during a spin, during a fixed cone beam. And it's actually relatively low, less than that of a low-dose CT scan, which most of these patients are going to be undergoing CT scans at regular intervals for the next five years of their life. So it's really not that much more radiation, comparatively speaking. The last system is the mobile 3D imaging with 2D fluoroscopy. This is primarily a fluoroscopic modality. It's not CT. But it does allow for 30-second portable CT-like imaging. It can verify tool and lesion. And it integrates directly now with shape-sensing software. And it's also portable and mobile. This is just a, hopefully, quick video that we'll play here that shows that the footprint of a mobile CRM is relatively small. You can use it while the robot is docked to the patient. And it's no different than a 2D footprint in terms of being able to easily rotate around the patient. Here we go. You can spin with your catheter in place and make micro-adjustments with everything docked. Typically, we do a breath hold while the spin is being performed to reduce artifact and motion during the spin. And then it provides you with images such as this, where you can confirm the catheter tip, confirm the location of the nodule, which was a ground glass nodule in this case. And then the target is updated so that you can re-navigate to now where the nodule is based on the CT that you just performed in the procedural suite. I think this is the last question. The following is the best unit to measure radiation dose with mobile CRMs. Is it millisieverts, dose area product, milligray, or the number of staff that are glowing after the case? It better be D. I love that somebody picked D, because that's important. Most of these cases are about protecting ourselves and our staff in addition to the patient. But actually, I'm glad there's a teaching point here. Dose area product is actually how you measure fluoroscopic modalities. The millisieverts and milligray are typically CT-based systems, and dose area product really factors in the amount of radiation dose that's received by a patient. How does that compare to fixed cone beam systems? Fixed cone beam can give you milligray, millisieverts, and the DAP. The mobile systems currently can only give you the DAP. For lung imaging, you need a complicated conversion factor to be able to go between the milligray and millisieverts to the gray per centimeter squared. This slide is just to demonstrate for mean fluoroscopy time for about eight minutes, which is what's been previously cited in the literature. In theory, the mobile spin does have less radiation, but it does have the opportunity to change between high-quality and low-quality imaging, so you can reduce your radiation dose, but potentially at the cost of less clear imaging and obscuring your nodule. So our personal experience at our institution, we still just use standard 2D fluoro for localization dye marking cases only because it's a game of horseshoes and you don't need to be right on the lesion. For most routine biopsies, the 3D mobile imaging with integration seems to suffice, and I think in over probably 150, 200 cases, there's been about four or five times that we've not been able to see the nodule on the mobile system. However, if we're doing a single-stage event, if the lesion is close to the vasculature, or for any reason we're worried about being able to see the lesion on the spin, we use our fixed 3D imaging, and body vision would probably be an acceptable alternative based on the literature that's available to date. Thank you. Don't forget to evaluate this session in the app, and we'll move on to the next talk. We'll save questions for the end. Thanks, everyone. Okay, I drew this short straw and I have 11 minutes to apparently tell you which robot is the best. I'm going to get hate mail from everybody probably. I'm going to try and keep this subjective. I'm biased. I've used Ion in over 500 cases and have a lot of experience with that, but I'm going to try and stick to the literature and see where we go, so let's talk about some robot wars here. All right, that's me. Those are my disclosures. I mean, I stay busy. As Kyle Hogarth would say, if you don't see your name up here, give me a call afterwards and we can talk. We'll get to the objectives when we get to the objectives. Okay, so there's two FDA-approved robots that are out there right now. Obviously, the Mark system from Ethicon now, not ORS anymore, and Ion from Intuitive. There's also, I don't know if you've heard of it, but there's a robot that's So, my name's Sonali Sethi. I'm at the Cleveland Clinic. I actually had a lot of fun putting this talk together, simply because there's not a lot of data that's available. We have some new stuff that just came out this year, but what I found is that without me realizing it, this is a question I ask myself every time before I start a case, am I supposed to stage this patient first or should I go and biopsy this patient first? So, I'm going to have you guys do a lot of audience response polling. I'm going to show you some data. The cases I'm going to show you are just from this past week alone to show you how different cases can be. And so, these are from my own Bronx suite. I have no conflicts that are related to this talk. So, we're going to do case one. So, this is a 78-year-old female smoker. She has a history of ovarian cancer and was recently diagnosed with melanoma of her left upper extremity. This was biopsy proven just recently. That wasn't bad enough. We've got to give her a stage four lung cancer as well. That was an adenocarcinoma and she was treated with chemotherapy back in 2017. She had a recent CAT scan imaging that was done and you can see there are two nodules here in the right upper lobe. There's a 2.5-centimeter nodule and a 1.6-centimeter nodule as well. Just to give you some more imaging, this is PET imaging that she had done that you can see here and some of the mediastinal lymph nodes that you can see on the imaging here as well. So, if this was your patient and this was your bronch suite, what is the next step you would do in your management? Would you start with navigation or robotic bronchoscopy? Would you start with staging EBOS? Would you refer this patient to a thoracic surgeon or would you start chemotherapy for metastatic melanoma? Again, the QR code is up there if you don't have it. You can get it on your phone quickly. You have two seconds to do that. Okay. So almost a split between starting with the navigation or robotic bronchoscopy versus starting with the staging E-Bus. So that's kind of interesting. In this case, I decided to start with the staging because it did look like that 4R lymph node was PET positive, plus one of those nodules on the right upper lobe I thought I could get with the E-Bus scope. So why navigate out to it when I could see that nodule right there through the trachea and biopsy it as well? So in this case, the 4R came back suspicious for malignancy on ROSE. That has now been confirmed and it is actually positive. And an E-Bus of the right upper lobe medial lung nodule came back as an adenocarcinoma. So let's take another case. So this is another case I had this week, a 70-year-old female smoker, has polycystic kidney disease and liver disease, has a renal and hepatic transplant in 2010, had a CAT scan imaging done, and was found to have a 2.4-centimeter nodule on the right lower lobe. And back in 2011, this nodule was 1.3 centimeters. We did not have PET imaging at this time for this patient. These are some of the mediastinal cuts that you can see here. What would you do for this patient in your bronch suite? Start with navigation or robotic bronchoscopy, start with a staging E-Bus, refer to a thoracic surgeon, or get a PET scan. You want all the cases. I hear you up here. She's going to burn herself. It's going to be one more second of grasshopper. Okay, so the majority of you here would start with navigation or robotic bronchoscopy, and I do think in this case this is the right answer. The reason for that is we've always thought that there is this concept of atelectasis that happens during our bronchoscopies, however, we were never sure, and then this fantastic paper came out by the MD Anderson group, and they actually proved that that is, in fact, what is happening. So these are images from bronchoscopies that they did, and in image A you can see there's that snowstorm appearance of normal aerated lung, but then in B you see there's this concentric nodule that you're seeing, in D you see there's eccentric nodule that you're seeing, C maybe there's a necrotic nodule that you're seeing, but what they found is none of these are nodules. This is all atelectasis that you are seeing on your radial probe Ebus. So what they saw when they did their study was the time to atelectasis was occurring within 30 minutes of you starting that procedure, and as time went on, more and more segments of atelectasis were occurring in patients. In fact, the atelectasis was more, as we would imagine, in the lower lobes, but it happens in the upper lobes as well, and when they did a logistic regression model on this and looked even closer, they found that BMI matters and the time to atelectasis matters, and so therefore this changes the way that we think now when we're going to nodules. You have to be able to navigate to that nodule quickly, or atelectasis is going to start to occur. So these are some images that were done with Conebeam. You can see here normal lungs, and then you can see the lung volumes at the time of the procedure, and you can see the atelectasis is already starting at the bases. These are actual cases that were done. You can see in that nodule that's in that right upper lobe, by the time you navigate it out to the nodule, it's gone. How are you going to get any imaging of that? The one in the middle, the same thing, and the one down there in the base, the same thing as well. So by the time you're getting out, your imaging is changing, and your radial probe might not be as accurate as you think that it is. So in this case, because of that, we did decide this is close to the diaphragm. It's in the bases. The lymph nodes I showed you on the mediastinal cuts did not look enlarged, so we went to robotic bronchoscopy first, got a mucinous adenocarcinoma. We then changed to an LMA. We did a staging anebis, which was negative. The PET scan obviously got done after that, and then the patient was referred to thoracic surgery. So what are the anesthesia considerations we need to take to try to avoid this atelectasis from coming? In the past couple of years, there's two great papers that have come out. One was actually Dr. Pritchett's paper here that we're going to talk about, and then one was from my own anesthesiologist, and it's a Cleveland Clinic protocol that we use. Both of these protocols are very similar. I'm just going to point out some important things here. So pre-procedure, you want to maybe consider performing incentive spirometry. Pre-oxygenation, you don't want to be oxygenating these patients at 100% anymore while you're doing your bronchoscopies. You want to keep that oxygenation at about 60% to 80%. In addition to that, you want to minimize atelectasis by avoiding that traditional rapid sequence intubation in these patients. You want to maintain optimal lung inflation. That means you want to use PEEP, high amounts of PEEP that we're using in these patients. Higher amounts of PEEP, especially for the lower lobes that you want to do. So we're talking 10 to 12 centimeters, and then even higher for the lower lobes, as a patient can tolerate. And then you want to do breath holds while you're doing spins around so that you can maintain that constant pressure and PEEP and control the diaphragm as you're spinning around to see actually where that nodule is to take care of the CT to body divergence that you're worried about. Our own protocol at the Cleveland Clinic, this is what we use. So we position the patient with their head up. At times, if they're really obese, we even try to see if we can go into reverse Trendelenburg. If the airways are not, we don't want to do that rapid sequence that we talked about, so we induce with propofol. And then as soon as they are induced, we then give the muscle relaxant at that point. We actually adjust our tidal volumes, so we use high tidal volumes in our patients. We go 10 to 12 milliliters per kilogram. And then we do that high PEEP that we spoke about in the last protocol. In addition to that, we do the breath holding as well. We generally do a breath hold at APL 20 that we ask the anesthesia staff to do at the time of the spins. So the recommendations, I think, the takeaways from both of these studies is that your rapid intubation needs to be done by an experienced anesthesiologist because you want to be able to navigate to that nodule quickly. That means these are not the cases you want the residents coming in and intubating on. You want the most experienced person in the room doing that intubation, whether it's your CRNA or the anesthesia staff themselves. You want to maintain muscle relaxation throughout the case. You want to use higher volumes of PEEP than you're used to using. Higher volumes of tidal volume as well. You want to minimize your FiO2, so you don't want to keep that on at 100% the entire case. You want to avoid excessive suction, and you don't want to wedge into that airway because wedging into that airway is going to cause adalectasis distal. You want to stay back if you can so that you can continue to ventilate. We're going to do breath holds, like I mentioned, at APL 20. Recruitment maneuvers, if your case is going longer, think of doing those, and you need to get that procedure done as quickly as possible. So last case, this was a 72-year-old male, 30-pack year smoker, had an abscess of the right groin and was found to have this 1.8-centimeter nodule in the right upper lobe. This actually was 1.1 centimeters in 2021. This is a PET scan that we had done. So on this nodule, the SUV was 3.9, and that right paratracheal lymph node SUV was 7.6. What is the next step that you're going to do for this patient? You're going to start with your navigation or robotic bronch, are you going to start with staging EVOS, are you going to refer to the thoracic surgeon, or are you going to do a fungal battery? I feel like we need Jeopardy music or something. It's too quiet. OK. So most people said here, starting with the staging ebus. Some people said a fungal battery, but the majority said starting with the staging ebus. So I'm going to show you this fascinating sign and paper that a lot of people may not be aware of. So I am in Cleveland. I have a lot of fungus where I am. I have a lot of histo. I get a lot of PET positive nodules that aren't actually cancer. There is actually this flip-flop fungus sign. And what this sign is is that when the lymph node SUV is higher than your nodule SUV, you're probably dealing with granulomatous disease. So it's probably some kind of fungal infection. In fact, the specificity of this sign is 84.9%. And if you actually have that positive fungal serology, that takes that specificity up to 100%. So for those of us that are in the Ohio River Valley fungal belt area, this is something we need to think of when we're trying to think of, should we go to the nodule first, or should we stage the patient first? So in this case, we did do the nodule first. We went out, and that was an adenocarcinoma. And that 4R and 11RS actually came back as granulomatous inflammation on the staging. Now, this is hot off the press. This is from the Vanderbilt group. And I'll leave it to Fabian to come up with some kind of complicated Monte Carlo simulation that I have to actually look up what this thing was. It made no sense to me. It's actually something that's used in the financial world. And it's this very complicated simulation thing that's used to predict what's going to happen to the markets in the future. However, what you do is you take things that you do know, absolutes that you know, and then you try to put it through thousands of different iterations. And then you see what the outcomes of those thousands of different iterations are going to be. So what he wanted to try to see, or what the group wanted to try to see, was should they start with an E-bis first, or should they start with a NAB-Bronc first? So what did they know? They know that the diagnostic yield from NAB-Bronc was 70%. I actually thought that was a little conservative. I think with the newer generation technologies we have, that it's actually higher. So they were very conservative in how they did this. They also know that in the E-bis, if the mediastinum, the lymph nodes don't look enlarged, the chance of picking up cancer from that's about 10%. They also knew that if you do the E-bis first, the diagnostic yield of getting an answer, if you do the NAB-Bronc afterwards, probably drops from 70 to about 60%. And so they put in these factors that they knew. They went through these thousands of different iterations with all the risks that are associated in different ways that patients could go through different pathways. And what they found was that if you actually did the NAB-Bronc first in all of these scenarios, there was a 12% less non-diagnostic bronchoscopies that you were getting. So you were actually getting a diagnosis 12% more of the time off of those nodules, if you went to that nodule first instead of doing the E-bis first. I actually think that number's probably higher. I think the numbers that they used were pretty conservative. So in the reality, it's probably a little bit higher. So this would go to show that we probably should be doing on all of our patients the NAB-Bronc first and doing the staging E-bis afterwards. So the takeaway point, you wanna stage prior to a lung nodule biopsy when there's obvious nodal disease that is gonna get you the diagnosis, right? So you can tell that with the PET scan, enlarged lymph node, something like that. That's when you wanna do the staging first. But you wanna go to the nodule first if the lymph nodes are small and atelectasis is a concern and you wanna be aware of positive PET imaging with that flip-flop sign I showed you because that could be a prediction of benign disease in the mediastinum. Thank you. Hi. Thanks for having me speak today. My name is Ryan Kern. I'm an interventional pulmonologist in a male clinic in Rochester. And I do have one relevant disclosure for today's talk. I do have some research funding from Irby, USA. And what I'm really here today to do is to talk about what tools we need when we do a bronchoscopic biopsy. So you may have your robots and your comb beam CT and your Monte Carlo. Don't ask me what that means still. But if you can't get a good piece of tissue, what's the point? And so that's really what I want to talk about today. So first off, I just have an audience poll. So what biopsy does your local lung oncologist, and we're not talking about Pinehurst here, generally prefer? Is it A, a CT-guided core needle biopsy, or B, some form of a guided bronchoscopic biopsy? So no right answer, just kind of curious what everyone prefers locally. Wow, well, I guess I don't know how many of these were industry answers, but I'm glad to see that. Well, I know that Dr. Pritchett doesn't like to call CT-guided biopsy the gold standard, but I do want to point out, this is a really good biopsy. This is a really high-quality biopsy, and it's still an engineering hurdle that needs to be solved in the world of bronchoscopy. For those of you who aren't familiar with what a true CT-guided core biopsy is, is most of the time, at least in the U.S., a 19-gauge hollow introducer is advanced right up to a nodule of interest, and then a 20-gauge core is passed through this. But these come in sizes between 8 millimeters all the way up to 22 millimeters, so they can basically go from end to end and fire a core. So pathologists love them because they get orientation, they get architecture, and they know that it's traversed the entire nodule. And they can also get a smear, they can get rows, so we actually get diagnosis the same day even from our CT core biopsies. And so engineering-wise, it's a straight line, so hard to do when you're thinking about monarch or ion, so the tools that we use in robotic bronchoscopy have to be able to make tons and twists and turns, and then when they actually make those twists and turns, they have to have enough backbone to actually penetrate into lesion of interest and get a biopsy. And so that's actually been quite an engineering hurdle. And so when you're thinking about what tools you could use with a robotic bronchoscopy platform, you have to know a few things that Dr. Pritchett discussed, but a few things that you might not know. So they have a working channel roughly of 2 to 2.1 millimeters. That's similar to what you see with your Olympus P190 or your MP190, which is down to 1.7. But standard bronchoscope that we use that's non-therapeutic has a 60-centimeter length working channel. You contrast that to robots, these are 100 to 105 centimeters. So if you're thinking about using a generation one cryoprobe, for example, it's not going to have the length. But now that you do know the lengths, I would encourage you, you know, late at night to raid your GI storage supplies to see what kind of cool things you can come up with. But to get to the kind of crux of this talk, you know, what are the tools that you should have in your toolbox? I think there are many, but the one that I think has really important presence when it comes to robotic bronchoscopy is the needle. The needle, I think, is intuitively popular for all of us who do E-Bus. We know that if we place the needle precisely, we can get great tissue. But we also know that if we're just, you know, if a nodule is off the bronchus and you're just putting the needle down the bronchus, it's not going to do anything. And so needles haven't been that popular, I think, you know, when I was training and really until the last few years. But robotic bronchoscopy platforms can now angle into the needle. So as Mike mentioned, airway signs don't really matter, and needle is really the backbone of this. Now, when we think about a needle, we have to think about more than just it being a needle. We have to also talk about the size. And so at Mayo, we often will like to start with a pretty small needle, like a 23-gauge needle, at least initially at the beginning of the navigation, particularly if out in the periphery. You know, you heard that atelectasis is really the enemy of cone beam CT. But any form of blood, hemorrhage fluid, or anything like that is going to mess up your radial probe image. It's going to mess up your cone beam CT. So if you think it's a hard nodule to get to and you might need to put the needle out there and perhaps do a CT spin or use some other confirmation technology, then you might need to do that a few times. If you use a big needle and you cause a lot of blood, you may look like you're dead center of that lesion when all you are is dead center of some blood that you created. So the 23-gauge needle is something to think about. The 19-gauge and the 21-gauge, I think, have more use, especially when you're in the more central airways, when you're more guarded by cartilage. Standard forceps, these are, of course, a big workhorse. They're cheap, readily available. Particularly, there's an airway going right to it. It's nice. However, they're not too good at traversing the bronchial wall. You know, a 2-millimeter outer diameter is the equivalent of a 14-gauge needle. So it's going to have to be a pretty big hole to get there. Standard brush, we don't use it a ton, but it can be readily available. It can penetrate through the bronchial wall, particularly if a needle's already been used. It might be useful in some cases. More mini forceps are probably things you haven't heard much about, at least as it relates to robotic bronchoscopy. These can be used for lymph node biopsy, but they're actually pretty good at penetrating the bronchial wall. They have a pretty good backbone. We've used them in cases where we wanted to get a bigger biopsy, and we've put the forceps through, opened them up, and then maybe dilated just a little bit of a track. And then Mike talked briefly about the 1.1-millimeter cryoprobe, which is exciting, I think, new development in the field of robotic bronchoscopy as far as biopsy tools go. These are roughly equivalent to a 19-gauge needle when you're thinking about their diameter, but because they do have a rounded tip, they will go right through the same hole that our needle goes through pretty reliably, even if we use a 21-gauge needle. And I'll talk a little bit more about that. And so when it comes to biopsy tools, there's been some really great studies done over the last five years or so looking at impacts of using a few tools versus many tools. And the one I thought that did the nicest analysis of this, at least that I could find, was a post hoc analysis of the NAVIGATE study. So for those of you who don't know, the NAVIGATE trial looked at over 1,200 patients from 29 centers, and they prospectively followed them for results from navigational bronchoscopy. What they did in this study is they took the 416 patients who actually had a cancer, and that cancer was diagnosed via the navigational bronchoscopy, and they looked basically how did they get that diagnosis? What tools did they use? And so the first thing they did is they divided them into two groups of patients. Remember, these all had malignancy. But they looked at the patients who underwent a biopsy using just a restricted set of tools, which they defined as forceps, brush, and or BIL, and then a more extensive set of tools including forceps, brush, needle, triple needle, and I'm not going to read them all, but a lot of different tools. And importantly, they found not only did most clinicians use more tools, that in itself doesn't really mean much because these patients all had cancer, but they had no increased complication rates by using more tools. And so I think that's important to know. And then they went a little bit further, and they took all of these tools and looked at what the diagnosis would have been in isolation had you omitted a tool. And so they found that the biopsy forceps and the needle accounted for the vast majority of diagnoses. However, if you took those away, there were still 28 patients who would not have otherwise been diagnosed with cancer if they didn't have these other tools used. So what we don't know here is since most of these patients didn't have a cone beam CT, is did more tools just result in more shots on goal, and they managed to hit the lesion? Or were they all hitting the lesion, and some of these tools just did a better job of putting the tool in the lesion or the lesion in the tool? We don't know which one it is. So that takes me to question two. So you've got a 56-year-old with a 30-pack-year tobacco history, no prior cancer history, normal pulmonary function tests, has a 13-millimeter PET-AVID nodule with no adenopathy. Patient has a robotic bronchoscopy. There's no airway leading directly to the tumor. You're going to have to poke through a bronchial wall to get there or tent into it or do it on direct visualization, depending on what platform you're using. A radial probe is inserted, but it just kind of flexes around the nodule, gives an eccentric view. And it just shows some very large vessels here, and here's a little bit of a better look at that nodule. You can see a couple airways, and you can see three very large vessels kind of going right around this nodule. So initial three passes are done, and this is actually a real case from two weeks ago. Initial three passes are done with a 21-gauge needle, and they all show diagnostic specimen on Rapid Onsite. So my question for the audience is, what is the next tool that you'd use here? Would you do three more needle passes for permanent section? Should you use forceps, brush forceps, or no further tools at all? So quite a split here. Well, I was hoping I could trick you, and I think there's room for a lot of different opinions here. But in this case, you've got a needle that's showing you abundant diagnostic specimen. You've got a 56-year-old who seems to be a very good surgical candidate. If this was one of Dr. Eisenhower's patients enrolled in the same day resection, you'd have this thing out. The lobe would be out before you'd know any molecular markers. However, I think it'd be totally reasonable to do three more needle passes for permanent section if you thought you wanted some DNA analysis. I think forceps, brushing forceps, although I just told you why it's important to use multiple tools, you've got a half a centimeter vessel sitting right next to where you're at. You're having to go through a bronchial wall. So maybe this is a time where you need to really trust in that needle. And if you haven't used a needle a lot, it takes a while to kind of get familiar to trusting it like you do with an E-bus. And so finally, question three. I have another patient from just a week or two ago. This is a 56-year-old, never smoker, history of multiple growing ground glass opacities and part solid nodules. Patient does have a history of a left lower lobectomy for a similar finding a couple years ago. This nodule that we see right here, there's no bronchus sign. Patient undergoes a robotic bronchoscopy. The radial probe is put out there. There's a questionable eccentric blizzard sign. I've never written that before. That just means ground glass opacity and an eccentric view. Initial three passes show rare suspicious cells on rows. What do you want to use next? Would you use a needle only, forceps, needle brush, forceps, and BAL, or 1.1 millimeter cryo probe if you have it available? I like these answers as well. I think both C and D would have been great answers, and I really wanted a good reason to talk about this 1.1 millimeter cryoprobe because I do think this is something exciting, and Dr. Pritchett just showed you some data, and it's so hot off the press I'm going to have to show you the same data in maybe a slightly different way. But this is what they look like under fluoroscopy. This is a 21-gauge needle. This is a cryoprobe. You can see visually they look pretty much the same, and in the same patient that I just showed you the last slide for, we can see that the needle on the left and the cryoprobe on the right make the same exact trajectory once you've made a few needle holes. So it does act like a kind of rounded, tipped needle. And the way I like to do this is if the needle is not drawing back any blood, I feel pretty good putting the cryoprobe out the same hole. I also like to have some sort of confirmation, if possible, where I'm at. And so this is just a couple representative PATH specimens from that exact patient. On the right here, we've got the 1.1-millimeter cryoprobe. This was just a four-second freeze. On the left, there's a forceps biopsy. But in this particular case, this is one of the most long-winded discussions you'll have at tumor boards, these patients who have multifocal lung adenocarcinoma. What do we do? Well, we know that they need to be multidisciplinary discussions. We know they might need to be in clinical trials, roll for molecular markers, various multimodality therapies all need to be discussed. I think getting a good, high-quality tissue here, particularly with this ground glass opacity, makes sense if that's the route chosen. And so there is some emerging data about the use of these mini cryoprobes in the periphery of the lung. There was a study done using EMN in China, looking at 23 patients with ground glass opacities or part-solid nodules. And they found that they had diagnostic specimen in 83% of these patients. There was an abstract presented at the Chess World Congress over the summer, looking at five patients with ground glass opacities or part-solid nodules, diagnostic and all-comers. And we just heard a couple slides ago about this hot-off-the-press study that's really great from Dr. Oberg and O from UCLA about the use of this novel cryoprobe and cryobiopsy. You had already heard there's 112 patients and 120 lesions. I do want to talk a little bit about their technique. They did a needle, they did a forceps, and then they did a 1.1 millimeter cryoprobe. They took three to four cryobiopsies with four to five second freezes, and they were able to extract the specimens right through the working channel. 18% of these diagnoses came exclusively from the cryobiopsy at a 5.4% pneumothorax rate. 2.7% of them needed a chest tube or had minor bleeding. And so I think this is just something that needs further study. We're actually doing a prospective study looking at some similar outcomes and looking forward to seeing what that shows. So in summary, how many tools do you need in your toolbox? I think you need at least the ones I showed you, or at least most of those. You know, you have to ask yourself, what's the goal of the procedure? Do I just need a confirmed diagnosis so that the patient can have their 1A resected, rule out infection or something like that, or do we need molecular markers or something else like that? And so just take a very patient-centric approach and you'll do great. Thank you.

bronchoscopic biopsies

tissue samples

tools

needles

forceps

brushes

cryoprobes

diagnosis

lesion characteristics