Robotic-assisted bronchoscopy a ‘game changer’ in early diagnosis of lung cancer
Key takeaways:
- Robotic bronchoscopy is now becoming the gold standard of care for small peripheral nodules.
- Robotic bronchoscopy is safe.
- Early detection of lung cancer can save lives.
Robotic bronchoscopy can help diagnose spots in the lungs when they are still small, catching cancer sooner and saving many more lives. The earlier you can diagnose someone with lung cancer, the more potential you have to cure them.
Robotic bronchoscopy has become a game changer.
The robot revolution
Traditionally, bronchoscopy had not been able to access nodules in the peripheral lung less than 20 mm, often due to the difficulty of reaching these peripheral areas. Additionally, the utilization of small gauge needles made bronchoscopy diagnostic yields very low.
CT guided biopsy, on the other hand, had the ability to localize the needle within the target in real time and, hence, has been the gold standard for diagnosing patients with smaller peripheral pulmonary nodules.
Due to these deficits, advances were made in bronchoscopy technology with the use of navigational platforms and small peripheral ultrasound probes.
The navigational platform enabled the proceduralist or physician to create a virtual pathway to the nodule, similar to a GPS map. This mapping allowed the physician to reach these small nodules. Despite these advances, yields continued to be low compared with CT guided biopsy, but they did increase to approximately 60% to 70%.
Then, along came robotics.
Robotic systems for bronchoscopies were first FDA approved for commercial use in 2018 and 2019. With the advent of robotics, there were also advances within scope technology.
Bronchoscopes had to become smaller and more maneuverable to travel through smaller generation airways to reach the peripheral aspects of the lungs. Robotic systems allow for a different approach, as physicians no longer hold the scope in their hand.
With this new technology, interventional pulmonologists are using controllers that are akin to an Xbox controller or a tracking ball with which one can control the scope. Being able to navigate safely, efficiently and accurately enables physicians to reach the spots that they believe indicate a high risk.
These systems have also made additional advances by the use of either electromagnetic navigation or shape-sensing catheters to accurately drive the catheter into the periphery and almost to the chest wall.
The greatest addition to advancing the practice, though, was the ability to have advanced imaging intraoperatively to now see the tool within the lesion, similar to CT guided biopsies.
Now with the improvements to steer, maintain stability and see your tool in real time, diagnostic yields have improved dramatically, allowing robotic bronchoscopy to be equivalent to the previous gold standard of CT guided biopsy.
In our field, that is truly a game changer. We have the ability now to reach these areas and accurately biopsy them.
Safety profiles
Common risk factors for lung biopsies are bleeding and collapse of the lung, known as a pneumothorax. From the literature, with CT guided biopsies, 15% to 20% of patients will get a pneumothorax, and 50% of those will require a chest tube.
Recent robotic bronchoscopy studies have revealed that the rate of bleeding and pneumothorax is significantly less when compared with CT guided biopsy. A recent survey indicated 19 patients with pneumothorax and seven with bleeding in a cohort of 679 patients with lung lesions who had robotic-assisted bronchoscopy.
Simply put, we are seeing substantially fewer adverse events with bronchoscopy.
The need for robotics
Lung cancer is a devastating disease. Deaths from lung cancer outnumber those from colon, breast and prostate cancer combined. Five-year survival rates for patients diagnosed with advanced lung cancer are less than 30%.
This is why early detection and screening are crucial. When physicians can reach the lung nodules and diagnose cancer in its early stages, the 5-year survival rate is greater than 60%.
High-risk patients — those aged 50 to 80 years who have a 20-pack year history of smoking and are currently asymptomatic — should be screened on a yearly basis with a low-dose CT to look for those spots.
Screening these high-risk patients can decrease mortality by 20% and save more lives. But although we have lung cancer screening guidelines, high-risk patients are not always screened.
By current estimates, there are approximately 13 million people in the United States who should be screened, but unfortunately, we are not getting close to these numbers. Only 16% of those eligible are being screened on a yearly basis. Further, patients need to be screened before they can be biopsied, and screenings are falling short.
In addition, providers have also become more aware of the need to manage and follow pulmonary nodules that are found incidentally, such as when patients get an X-ray or CT scan after an automobile accident.
The focus on finding nodules in these earlier stages or smaller states pushed the need to advance bronchoscopy. Literature has showed that 70% of early stage lung cancers are often located within the periphery of the lung.
Therefore, the need to not only reach these areas but also minimize the patient risk during a procedure has pushed these advances within the robotic community.
More greatly, the advancement of tool-in-lesion has overcome the previous deficits once faced by early robotic bronchoscopy. Tool-in-lesion technology enables proceduralists to overcome the concept of CT-body divergence and allows for more accurate sampling.
Challenges remain
Technologies are expensive, so they must be shown to be cost-effective before more hospital systems can take advantage of them.
One second-generation bronchoscopy robot includes tool-in-lesion tomography, negating the need to purchase other pieces of equipment. This can be a real cost saver for some hospital systems, reducing financial barriers for hospitals and improving accessibility to patients.
Robotic bronchoscopy has become a game changer. It is allowing us to reach smaller peripheral pulmonary nodules in high-risk patients, which enables us to diagnose lung cancers at early stages and ultimately save more lives.
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Sy Sarkar, MD, is a board-certified interventional pulmonologist and director of interventional pulmonary services, Mercy Medical Center. Clara Yoder, BSN, RN, CCRN, is a lung clinical nurse navigator at Mercy Medical Center.