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Sandeep Sachidananda, MD1, Cristobal Alvarado, MD2.
1Waterbury Hospital, Waterbury, CT, USA, 2Hartford Healthcare Medical Group, Meriden, CT, USA.

OBJECTIVE: With the widespread implementation of low dose CT screening for lung cancer, we have an increasing number of small solitary pulmonary nodules which require a diagnosis. ENB is a new minimally invasive diagnostic modality. However, it is limited by its diagnostic accuracy of 60-80%. We propose the use of ENB with CBCT guidance to overcome the visual limitations of ENB and potentially increase the diagnostic accuracy of ENB aided biopsy.
METHODS: Patients with undiagnosed small pulmonary nodules (less than 20 mm) underwent biopsy where an initial CBCT of the chest under breath hold was performed, followed by a 3-D model reconstruction of the lesion while the surgeon started the ENB. At the end of the bronchoscope navigation the 3-D model of the lesion was fused and automatically registered in real time over the 2-D fluoroscopic image allowing visualization of the biopsy tool in the target lesion in three dimensions. Multiple samples were collected after confirmation of the tool position using various oblique views.
RESULTS: In our initial experience with 10 cases CBCT acquisition, reconstruction and 3-D overlay was successful in all cases. This technique enabled the confirmation of biopsy tool position within the target lesion in all cases. We were able to successfully and accurately obtain biopsies of nodules ranging from 8-20 mm in size.
CONCLUSIONS: Use of intraoperative CBCT with real time 3-D overlay to confirm positioning of biopsy tool within the lesion during ENB is technically feasible. It effectively combines the advantage of real time CT imaging with advantages of ENB aided biopsy. This potentially increases the diagnostic accuracy of ENB aided biopsy by enhanced visualization. This novel technique will facilitate early accurate diagnosis of lung cancer in small nodules with a minimally invasive approach. The enhanced visual capabilities of ENB with CBCT guidance paves way for the future use of minimally invasive catheter based therapeutic platforms like microwave, radiofrequency ablation etc. safely.

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